COLUMBIA  LIBRARIES  OFFSITE 

HEALTH  SCIENCES  STANDARD 


HX00066664 


RECAP 


--^''"^^ii^^^m 

JrSi^s? 

^■■1 

^^R 

^b^\m'i^^^m 

^^?:      ■ 

'r*?-::  :  -.  •. 

^ 

^mmwmsm 

^ 

RC3II 


QP-'^ 


COLUMBIA    UNIVERSITY 
EDWARD   G.   JANEWAY 
MEMORIAL  LIBRARY 


Digitized  by  tine  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/handbookonprevenOOchar 


A   HANDBOOK 


ON  THE 


Prevention  of  Tuberculosis 


BEING  THE  FIRST  ANNUAL  REPORT 

OF  THE 

COMMITTEE  ON  THE  PREVENTION  OF 
TUBERCULOSIS 

OF 

THE  CHARITY  ORGANIZATION  SOCIETY 
OF  THE  CITY  OF  NEW  YORK 


PUBLISHED    BY 

THE  CHARITY  ORGANIZATION  SOCIETY 

NEW  YORK  CITY 

1903 


"Cbe  "Rntcberbocher  press 

(G.  P.  Putnam's  Sons) 

IRew  ]3orft 


THE    COMMITTEE    ON  THE   PREVENTION 
OF  TUBERCULOSIS 

OF 

THE  CHARITY  ORGANIZATION  SOCIETY 
OF  THE  CITY  OF  NEW  YORK 


Charles  F.  Cox,  Chairman 
Otto  T.  Bannard 
Hermann  M.  Biggs,  M.  D. 
Herbert  S.  Brown 
Joseph  D.  Bryant,  M.  D. 
Miss  Ella  Mabel  Clark 
Robert  W.  de  Forest 
Edward  T.  Devine 
Homer  Folks 
Franklin  H.  Giddings 
J.  H.  Huddleston,  M.  D. 
Robert  Hunter 
a.  jacobi,  m.  d. 
Walter  B.  James,  M.  D. 
E.  G.  Janeway,  M„  D. 


S.  A.  Knopf,  M.  D. 
Alexander  Lambert,  M.  D. 
Ernst  j!  Lederle 
Mrs.  Frederic  S.  Lee 
Egbert  Le  Fevre,  M.  D. 
Henry  P.  Loomis,  M.  D. 
Mrs.  James  E.  Newcomb 
Eugene  A.  Philbin 
Ernest  Poole 

T.  Mitchell  Prudden,  M.  D. 
Andrew  H.  Smith,  M.  D. 
W.  G.  Thompson,  M.  D. 
E.  L.  Trudeau,  M.  D. 
Fred'k  L.  Wachenheim,  M.  D. 
R.  C.  W.  Wadsworth 
Miss  Lillian  D.  Wald 


Miss  A.  B.  Jennings 

Miss  Lilian  Brandt,  Statistician 

Paul  Kennaday,   Secretary 
/qj  East  22d  Street,   New  York  City 


PREFACE 

This  Handbook  on  the  Prevention  of  Tuberculosis  is  a  con- 
tribution of  the  New  York  Charity  Organization  Society  to- 
wards the  world-wide  movement  to  put  an  end  to  the  most 
deadly  and  most  needless  scourge  with  which  humanity  is 
afflicted.  It  is  inspired  by  a  confident  hope  in  the  success  of 
this  movement.  Relief  for  the  individual  consumptive,  abun- 
dance of  plain  and  suitable  food,  uncontaminated  air  in  living 
and  sleeping  rooms,  the  provision  of  sanatoria,  dispensaries, 
nurses,  and  physicians  for  those  who  are  sick  and  who  cannot 
themselves  pay  for  these  necessities,  are  among  the  means  to 
this  end. 

The  Committee  on  the  Prevention  of  Tuberculosis,  whose 
first  annual  report  is  included  in  this  volume,  seeks  to  co- 
ordinate the  various  agencies  at  work  in  this  field,  and  to 
promote  appropriate  action  by  state,  municipality,  private  in- 
stitutions and  individual  citizens.  It  is  needful  to  allay  base- 
less fears  of  harm  from  the  mere  proximity  of  consumptives 
who  are  instructed  and  conscientious.  The  Committee  aims  to 
diminish,  not  to  increase,  the  hardships  of  those  who  are  ill ; 
but  it  insists  that  it  is  the  duty  of  the  community  to  give  them 
a  chance  to  get  well  while  they  are  curable,  and  to  isolate  such 
as,  through  persistent  carelessness  or  for  other  reasons,  are 
really  a  source  of  danger  to  their  fellows. 

It  is  hoped  that  the  handbook  will  be  of  service,  not  only  in 
New  York  City,  but  to  those  who  are  organizing  similar  move- 
ments elsewhere.  There  are  indications  that  in  many  com- 
munities conditions  exist  similar  to  those  which  led  to  the 


formation  of  this  Committee.  The  demand  for  information 
concerning  its  origin,  scope,  and  methods  of  work  has  led  the 
Committee  to  include,  with  this  first  annual  report,  not  only 
a  review  of  the  year,  but  as  much  as  possible  of  the  material 
prepared  under  the  auspices  of  the  Committee,  whether  for 
lectures  or  for  publication.  Some  of  this  material  has  pre- 
viously been  published  in  Charities,  the  An^ials  of  tJie  American 
Academy  of  Political  and  Social  Science,  Harper  s  Mont Jily,  and 
The  New  York  Medical  Record ;  and  acknowledgment  is  made 
of  the  courtesy  of  the  publishers  of  those  periodicals  in  per- 
mitting its  reproduction. 


CONTENTS 

PAGE 

Members  of  the  Committee       .         , iii 

Preface      ...........        v 

Review  of  the  First  Year  :   1902-3 3 

Financial  Report       .........       25 

Appendix  i. — The  Social  Aspects  of  Tuberculosis,  Based  on 

a  Study  of  Statistics.     Lilian  Brandt  .         .         .         -31 

Appendix  2. — Schedule  for  Recording  the  Social  History  of 

Cases  of  Consumption        .         .         .         .         .         .         .119 

Appendix  3. — Some  Social   Aspects  of  the  Tuberculosis  In- 
firmary, Blackwell's  Island.      Hon.   Homer  Folks,  Com- 
missioner of  Public  Charities  of  the  City  of  New  York     .     125 
Appendix  4. — A    List  of  Lectures  Delivered  under  the  Aus- 
pices of  the  Committee  on  the  Prevention  of  Tubercu- 
losis during  the  Winter  of  1902-3    .....     137 

Appendix  5. — Germs  of  Consumption  :  What  They  Are  and 

What  They  Do.     J.  H.  Huddleston,  M.D.         .         .         .     i45 

Appendix  6. — Tuberculosis  :  Its  Causation   and    Prevention. 

Hermann  M.   Biggs,  M.D 153 

Appendix  7. — The  Duties  of  the  Individual  and  the  Govern- 
ment in  the  Combat  of  Tuberculosis.     S.  A.  Knopf,  M.D.     173 
Appendix  8. — Tuberculosis  and  Children.     A.  Jacobi,  M.D.  .     207 
Appendix  9. — The    Climatic    and    Sanatorium    Treatment  of 

Consumption.     Henry  P.  Loomis,  M.D.    ....     227 
Appendix  10. — Tuberculosis  and  Its  Prevention.     T.  Mitchell 

Prudden,  M.D. 243 

vii 


Appendix  II. — Leaflet':  Warfare  against  Consumption  .         .      263 

Appendix  12. — Circular:  Information  for  Consumptives  and 
Those  Living  with  Them,  Issued  by  the  Department  of 
Health  of  New  York  City 267 

Appendix  13. — Plans  for  a  Municipal  Sanatorium.      Messrs. 

Renwick,  Aspinwall,  &  Owen    .         .         .         .         .         -273 

Appendix  14. — Plans  for  a  Municipal  Sanatorium.      Messrs. 

Howells  &  Stokes     ........     287 

Appendix  15. — Municipal  Sanatorium  for  Incipient  Cases  of 
Tuberculosis.  A  Report  from  the  Hon.  Homer  Folks, 
Commissioner  of  the  Department  of  Public  Charities,  to 
the  Board  of  Estimate  and  Apportionment  of  the  City 
of  New  York,  July  15,  1903       ......     293 

Appendix  16. — The  Plague  in  Its  Stronghold  :  Tuberculosis 

in  the  New  York  Tenement.     Ernest  Poole      .         .         .     305 

Appendix  17. — The  Management  of  Cases  of  Pulmonary 
Tuberculosis  in  the .  Dispensary.  James  Alexander 
Miller,  A.M.,  M.D 333 

Appendix-  18. — Institutions  where  Tuberculous  Patients 
may  Receive  Treatment,  in  New  York  City  and  Vicinity. 
Charles  H.  Johnson  ........     347 

Appendix  19. — Sanatoria  and  Hospitals  for  Consumptives  in 
the  United  States  and  Canada.  A  Partial  List.  Collected 
by  S.  A.  Knopf,  M.D 359 

Appendix  20. — A  Brief  List  of  Important  Works  in  Regard  to 

Tuberculosis.     Selected  by  S.  A.  Knopf,  M.D.         .         .     365 

Index .         .         .371 


REVIEW   OF   THE   FIRST  YEAR:   1902-3 


REVIEW  OF  THE  FIRST  YEAR:    1902-3 

The  Committee  on  the  Prevention  of  Tuberculosis,  appointed 
by  the  Charity  Organization  Society,  held  its  first  meeting  on 
Monday  afternoon,  June  i6,  1902,  at  the  office  of  the  Society, 
for  the  purpose  of  organization.  The  scope  and  general  plans 
of  the  Committee  were  at  that  time  outlined,  and  the  work  of 
carrying  them  out  was  begun  the  following  September. 

The  considerations  and  circumstances  leading  to  the  appoint- 
ment of  this  Committee  and  the  basis  on  which  it  began  its 
work  were  stated  in  the  twentieth  annual  report  of  the  Charity 
Organization  Society,  as  follows: 

"Just  at  the  close  of  the  year  covered  by  the  present  report, 
the  Central  Council  initiated  a  movement  which  may  prove  to 
be  of  more  importance  than  any  other  in  which  the  Society  has 
participated  in  recent  years.  This  was  the  appointment  of  the 
Committee  on  the  Prevention  of  Tuberculosis,  consisting  of 
sixteen  representative  physicians  and  sixteen  others  who  are 
especially  interested  in  the  social  aspect  of  the  disease.  In 
many  respects  the  methods  of  work  adopted  by  the  new  Com- 
mittee will  be  similar  to  those  which  were  employed  in  the 
case  of  the  Tenement  House  Committee.  Like  the  former 
committee,  this  one  will  be  representative  in  character.  For 
example,  both  Dr.  Ernst  J.  Lederle,  Commissioner  of  Health, 
and  Dr.  Hermann  M.  Biggs,  medical  officer  of  the  Health  De- 
partment ;  Mr.  Homer  Folks,  Commissioner  of  Public  Chari- 
ties, and  Mr.  Robert  W.  de  Forest,  President  of  the  Charity 
Organization    Society    and    Commissioner   of   the   Tenement 

3 


House  Department,  are  members  of  the  Committee.  Co- 
operation will  be  sought  not  only  with  charitable  agencies  of 
all  kinds,  but  with  city  departments  and  State  officials.  At- 
tention will  be  devoted  to  educational  propaganda  and  the 
support  of  the  public  press  will  be  especially  sought. 

"The  services  of  a  competent  secretary,  a  district  nurse,  and 
a  statistician,  who  will  devote  their  entire  time  to  the  Com- 
mittee, have  been  secured,  and  at  the  same  time,  in  so  far  as 
it  will  be  of  advantage,  the  entire  volunteer  body  of  workers 
and  the  expert  agents  and  visitors  of  the  Society  will  con- 
tribute to  the  objects  which  it  is  desired  to  accomplish. 

"The  first  task  will  be  an  exhaustive  investigation  of  some  of 
the  social  aspects  of  tuberculosis.  There  are  already  in  pro- 
gress in  many  laboratories  investigations  of  a  bacteriological 
character ;  and  in  the  hospitals  and  sanatoria  there  is  oppor- 
tunity for  clinical  study  and  investigation  into  the  physical 
aspects  of  the  disease.  Little  attempt,  however,  has  been 
made  to  establish  the  relation,  for  example,  between  infected 
living  apartments  and  the  victims  of  the  disease ;  or  into  the 
possibility  of  recovery  or  improvement  resulting  from  im- 
proved diet  and  improved  light  and  air,  when  patients  are 
treated  in  their  own  homes;  nor  has  there  been  any  systematic 
effort  to  ascertain  how  far  infection  can  be  prevented  by  in- 
struction in  the  nature  of  the  disease  and  in  the  character  of 
the  precautions  which  should  be  taken  to  prevent  its  spread. 
In  several  foreign  countries  and  in  some  parts  of  the  United 
States,  as  well  as  in  Canada,  there  have  been  organized  socie- 
ties for  the  prevention  of  tuberculosis,  their  chief  functions 
being  the  dissemination  of  leaflets  and  of  information  in  other 
forms  concerning  the  communicability  of  the  disease,  the  dis- 
infecting of  apartments  where  deaths  have  occurred,  and  the 
necessity  of  conscientious  care  on  the  part  of  consumptives, 
especially  as  to  the  danger  of  spitting  in  hallways,  public  con- 
veyances, or  on  the  street.  Educational  and  practical  work 
of  this  kind  is  of  the  utmost  importance,  and  the  Committee 
will  undertake  to  carry  on  such  work  on  a  large  scale  at  the 
same  time  that  its  investigations  are  in  progress. 

4 


"In  co-operation  with  relief  agencies  it  is  hoped  that  much 
additional  information  may  be  obtained  concerning  the  desira- 
bility of  making  an  entire  change  in  the  physical  environment 
of  those  who  are  suffering  from  the  disease,  even  when  this 
involves  considerable  financial  outlay.  The  financial  burden 
imposed  by  the  existence  of  20,000  consumptives  in  New 
York  City  is  enormous,  and  on  the  financial  side  alone,  there- 
fore, it  may  be  found  a  good  investment  to  cure  tuberculosis 
in  its  incipient  stages,  rather  than  to  allow  almost  the  entire 
number,  as  at  present,  to  become  a  burden  either  upon  their 
immediate  family  or  upon  the  public  in  the  last  stages  of  the 
disease. 

"The  Committee  wish  especially  to  emphasize  the  fact  that 
this  movement  is  not  in  any  sense  one  against  consumptives, 
nor  one  that  will  be  permitted  in  any  way  to  increase  the 
already  great  hardships  of  their  lot.  In  some  quarters  there  is 
a  tendency  to  exaggerate  the  danger  of  casual  contact  with 
tuberculous  patients.  It  is  believed  that  there  is  no  occasion 
for  any  panic  or  public  apprehension  from  the  existence  in 
a  community  of  consumptive  patients,  provided  a  reasonable 
degree  of  prudence  is  exercised.  Complete  isolation  of  all 
consumptives  would  be  an  utterly  impracticable  proposition. 
Undue  restraint  upon  the  liberty  of  patients  in  moving  from 
one  place  to  another,  or  any  such  general  dread  of  the  disease 
as  will  make  it  more  difficult  for  those  who  have  had  tubercu- 
losis but  have  been  cured,  or  for  those  who  are  improving  and 
are  conscientious  in  caring  for  their  own  sputum,  thus  prevent- 
ing the  infection  of  others,  to  find  employment,  is  to  be  depre- 
cated. The  ruling  of  the  immigration  authorities  that  all 
consumptives  would  be  excluded  on  the  ground  that  their  dis- 
ease is  dangerously  contagious  is  an  instance  of  action  of  this 
kind.  Only  six  intending  immigrants  were,  however,  excluded 
under  this  ruling  between  January  i,  1902,  and  August  31, 
1902,  obviously  much  less  than  the  number  arriving.  The 
total  number  of  persons  returned  to  foreign  countries  in  this 
period  who  were  afifiicted  by  tuberculosis  was  twenty-six,  but 
twenty  were  brought  to  the  Commissioner  from  various  places 

5 


for  deportation  under  the  one-year  clause,  i.  e.,  because  they 
had  become  public  dependents  within  one  year  of  their  arrival. 
A  systematic  attempt  to  spread  accurate  information  concern- 
ing what  is  definitely  known  about  the  disease  will  be  of  benefit 
to  individual  consumptives,  and  will  eventually,  it  is  hoped, 
contribute  to  the  lessening  of  the  present  high  death-rate  from 
the  disease. 

"The  present  Committee  is  not  the  first  attempt  that  has 
been  made  to  perfect  an  organization  of  this  kind,  and  one  of 
the  most  hopeful  things  in  connection  with  its  formation  is  that 
the  earlier  attempts  in  the  same  direction  are  merged  into  it. 
Last  winter,  largely  upon  the  initiative  of  Dr.  S.  A,  Knopf,  a 
call  was  circulated  for  a  meeting  to  form  a  society  for  the 
purpose  of  fighting  tuberculosis.  Many  of  those  who  have 
now  become  members  of  the  new  Committee  signed  this  call. 
Owing  to  the  difficulty  of  finding  a  layman  with  the  proper 
qualifications  for  the  position  of  president  of  the  society,  the 
formation  of  the  society  was  not  consummated  and  the  phy- 
sicians who  have  been  interested  in  the  matter  have  cordially 
endorsed  the  present  plan  by  which  the  executive  and  clerical 
work  of  the  Committee  will  be  attended  to  in  the  offices  of 
the  Charity  Organization  Society,  while  the  scientific  and  pro- 
fessional guidance  required  will  be  supplied  by  those  who  are 
competent  to  give  it. 

"Aside  from  the  investigation  above  described  in  the  social 
aspects  of  tuberculosis,  the  objects  of  the  Committee  have 
been  formulated  in  part  as  follows ; 

"I.  The  promulgation  of  the  doctrine  that  tuberculosis  is  a 
communicable,  preventable,  and  curable  disease. 

"II.  The  dissemination  of  knowledge  concerning  the  means 
and  methods  to  be  adopted  for  the  prevention  of  tuberculosis. 

"III.  The  advancement  of  movements  to  provide  special 
hospitals,  sanatoria,  and  dispensary  facilities  for  consumptive 
adults  and  scrofulous  and  tuberculous  children  among  the  poon 
IV.  The  initiation  and  encouragement  of  measures  which 
tend  to  prevent  the  development  of  scrofula,  and  other  forms 
of  tubercular  diseases." 

6 


On  September  15,  an  appeal  for  funds  was  issued,  embody- 
ing a  statement  of  the  objects  of  the  Committee.  This  appeal 
read  as  follows : 

"The  Charity  Organization  Society's  Committee  on  Tuber- 
culosis needs  not  less  than  $10,000  to  meet  the  expenses  of  the 
work  which  it  has  undertaken.  Contributions  made  to  the 
Society  for  its  usual  current  operations  should  not  be  reduced 
and  cannot  be  diverted  in  any  large  amount  to  the  purposes 
of  this  special  Committee.  The  expenditures  to  be  made  by 
the  Committee  will  be  for  the  following  main  objects : 

"i.  Research  into  the  social,  as  distinct  from  the  medical, 
aspects  of  tuberculosis :  for  example,  into  the  relations  be- 
tween the  disease  and  overcrowding,  infected  tenements  and 
unhealthy  occupations,  and  also  into  the  influence  upon  re- 
covery of  improved  diet  and  hygienic  living. 

"2.  Education.  The  publication  of  leaflets  and  pamphlets, 
the  giving  of  lectures,  and  the  promulgation  in  every  possible 
way  of  the  fact  that  tuberculosis  is  a  communicable  and  pre- 
ventable disease ;  the  widest  distribution  of  the  results  of 
scientific  research  in  this  field,  and  of  the  results  of  modern 
treatment  both  in  sanatoria  and  at  home. 

"3.  The  encouragement  of  movements  for  suitable  public 
and  private  sanatoria  both  for  advanced  and  for  incipient 
cases ;  for  adults  and  for  children ;  for  free  care  and  also  for 
the  care  of  those  who  can  pay  moderate  fees. 

"4.  The  relief  of  indigent  consumptives  by  the  provision  of 
suitable  food  and  medicines,  by  the  payment  of  rent  when  this 
is  nec?essary  to  secure  adequate  light  and  air,  and  by  transpor- 
tation and  maintenance  at  a  distance,  when,  in  the  judgment 
of  the  Committee,  this  is  essential. 

"The  labors  of  the  Committee  will  be  directed  not  only  to- 
wards the  amelioration  of  the  condition  of  the  large  class  of 
consumptives,  but  also  towards  the  benefit  of  the  community 
as  a  whole,  in  which  there  is  encouraging  reason  to  believe  that 
tuberculosis  may  be  practically  eradicated.  The  work  of  the 
Committee  is  not  intended  to  be  temporary  merely,  but  its 

7 


continuance   and   effectiveness    will   depend   upon   the   public 
encouragement  and  support  received. 

"For  research  and  publication  the  Committee  can  easily 
make  use  of  the  $10,000  asked  for,  and  could  employ  a  larger 
sum  to  good  purpose.  In  the  relief  of  special  cases  existing 
agencies  will  be  asked  to  co-operate,  but  any  funds  which  in- 
dividuals may  be  willing  to  supply  for  this  special  purpose  will 
lessen  the  burden  upon  organizations  which  are  already  over- 
taxed by  cases  of  need  arising  in  large  numbers  from  the  class 
of  consumptive  poor." 

The  work  of  the  Committee  has  been  carried  on  along  the 
lines  laid  down  in  this  prospectus. 

I. — RESEARCH    INTO  THE  SOCIAL  ASPECTS  OF  TUBERCULOSIS. 

The  results  of  this  part  of  the  work  are  presented  in  one  of 
the  appendices  to  this  report  (Appendix  i).  All  available 
statistics  in  the  United  States  Census  and  in  the  reports  of 
the  New  York  City  Department  of  Health  have  been  studied. 
By  the  courtesy  of  the  registrar  and  other  officials  of  the  De- 
partment of  Health,  all  of  the  records  there  have  been  opened 
to  us  and  they  have  afforded  much  valuable  material.  This 
investigation  into  the  social  aspects  of  the  disease,  made  by  the 
statistician  of  the  Committee,  Miss  Lilian  Brandt,  has  formed 
the  basis  for  a  series  of  articles  in  Charities,  a  paper  in  the  May 
(1903)  issue  of  the  Annals  of  the  American  Academy  of  Political 
and  Social  Science,  several  newspaper  articles,  and  a  lecture 
before  the  Summer  School  in  Philanthropic  Work. 

A  schedule  (Appendix  2)  was  framed  early  in  the  year*  call- 
ing for  a  comparatively  full  social  history  of  cases  of  consump- 
tion. It  is  being  used  at  the  Phthisis  Infirmary  on  Blackwell's 
Island  and,  with  some  modifications,  at  Vanderbilt  Clinic. 
Similar  records  are  being  kept  also  at  several  other  institutions 
in  regard  to  cases  from  the  tenement  districts  of  Manhattan. 
Altogether  they  will  afford  material  for  a  more  detailed  social 
study  than  has  ever  been  made. 

The  account  by  Commissioner  Folks  of  the  conditions  of 

8 


life  from  which  the  men  in  the  Phthisis  Infirmary  come  (Ap- 
pendix 3)  is  based  on  the  first  of  these  records  collected  by 
the  Phthisis  Infirmary. 

II.— EDUCATION. 

The  education  of  the  public  in  regard  to  the  nature  of  the 
disease  and  the  precautions  which  should  be  taken  to  prevent 
its  spread  has  been  undertaken  by  means  of  lectures  and 
literature. 

The  lectures  were  given  by  members  of  the  Committee  or 
physicians  recommended  by  the  Committee.  The  total  num- 
ber for  the  winter  was  eighty-one,  with  an  aggregate  attendance 
of  8700.  The  list  of  places  in  which  the  lectures  took  place 
(Appendix  4),  including  as  it  does  settlements,  churches, 
mothers'  clubs,  young  men's  associations,  public  schools,  and 
Teachers  College,  and  the  number  of  languages  in  which  they 
were  given — English,  Yiddish,  Italian,  French,  and  German, — 
are  evidence  of  the  variety  in  the  audiences. 

Several  courses  of  lectures  were  arranged.  One  was  de- 
livered in  the  Assembly  Hall  of  the  United  Charities  Building, 
and  was  designed  especially  for  practical  social  workers.  The 
program  was  as  follows : 

November  10,  8  P.M. — Germs  of  Consumption:  What  they 
are  and  what  they  do.     Dr.  J.  H.  Huddleston.     Appendix  5. 

December  8,  8  P.M. — Causation  and  Prevention.  Dr.  H. 
M.  Biggs.     Appendix  6. 

February  9,  8  P.M. — The  Duties  of  the  Government  and 
the  Individual  in  the  Combat  of  Tuberculosis.  Dr.  S.  A. 
Knopf.     Appendix  7. 

March  9,  8  P.M. — Tuberculosis  and  Children.  Dr.  A. 
Jacobi.     Appendix  8. 

April  13,  8  P.M. — Sanatoria  and  Climatic  Influences.  Dr. 
Henry  P.  Loomis.     Appendix  9. 

Another  course,  of  four  lectures,  was  arranged  for  the  West 
Side  Branch  of  the  Young  Men's  Christian  Association;  still 
another,  of  three,  for  the  East  Side  Janitors'  Association. 

9 


Co-operation  with  the  Board  of  Education  resulted  in  thir- 
teen of  its  twenty-seven  lectures  on  the  subject  of  tuberculosis 
being  given  by  physicians  from  the  Committee's  list. 

Many  of  the  lectures  were  illustrated  by  stereopticon  views 
and  in  general  the  interest  aroused  was  gratifying. 

It  is  significant  that  in  the  Summer  School  of  Philanthropic 
Work  the  subject  of  tuberculosis  was  considered  of  sufficient 
importance  to  be  allotted  two  days  out  of  the  brief  six  weeks 
of  its  duration.  The  first  of  the  two  lectures  was  given  by 
Dr.  S.  A.  Knopf,  and  dealt  with  "What  the  Charity  Worker 
should  Know  of  the  Treatment  and  Prevention  of  Tubercu- 
losis." On  the  second  day  Miss  Brandt  spoke  of  the  "Social 
Factors  in  the  Prevalence  of  Consumption." 

The  work  of  education  has  also  been  carried  on  through  the 
distribution  of  literature.  Six  thousand  copies  of  the  four- 
page  leaflet  Warfare  against  Consumption  (Appendix  ii)  have 
been  distributed,  mainly  in  connection  with  the  lectures;  the 
House  of  Refuge  on  Randall's  Island  received  seven  hundred. 
It  thus  reached  chiefly  a  tenement-house  population.  Nine 
thousand  copies  of  Dr.  Biggs's  pamphlet.  Tuberculosis — Its 
Causation  and  Prevention  (Appendix  6),  have  been  distributed 
among  the  public  libraries,  the  insurance  companies,  and  the 
larger  railroad  offices.  The  essay  by  Dr.  Prudden  (Appendix 
lo)  has  been  distributed  among  the  school  teachers  of  Manhat- 
tan and  the  Bronx. 

A  circular  of  Information  for  Consumptives  and  those  Living 
with  them  (Appendix  12)  was  issued  by  the  Department  of 
Health  in  the  spring  and  fifty  thousand  copies  of  it  turned  over 
to  this  Committee  for  distribution.  This  circular  is  designed 
primarily  for  tenement  dwellers.  The  English  bears  on  the 
obverse  a  translation  in  German  or  Yiddish  or  Italian.  Of  the 
fifty  thousand  copies,  about  nineteen  thousand  were  distributed 
during  the  summer  through  day  nurseries,  kindergartens,  the 
industrial  schools  of  the  Children's  Aid  Society,  employment 
bureaus,  settlements,  branches  of  the  public  library,  and  relief 
societies. 

Five  thousand  copies  of  Dr.  Knopf's  lecture.  The  Duties  of 

10 


tJie  htdividiial  and  the  Government  in  the  Combat  of  Tubercu- 
losis (Appendix  y),  are  ready  now  for  distribution.  The  lecture 
given  by  Dr.  Jacobi  on  Tuberculosis  and  Children  (Appendix 
8)  is  about  to  be  reprinted  from  Charities  and  distributed. 
Two  sets  of  plans  for  a  Municipal  Sanatorium  and  Commis- 
sioner Folks's  report  to  the  Board  of  Estimate  and  Apportion- 
ment, which  will  be  spoken  of  later,  have  also  been  printed  in 
pamphlet  form,  one  thousand  of  each  (Appendices  13,  14,  15). 
Five  thousand  copies  of  Mr.  Poole's  descriptive  .pamphlet, 
The  Plague  in  its  Strongliold  (Appendix  16),  have  just  come 
from  the  press  and  will  doubtless  do  much  to  make  the  public 
realize  the  sufferings  brought  on  the  poor  by  this  preventable 
disease. 

Finally,  a  second  appeal  for  funds  has  been  drawn  up,  set- 
ting forth  a  number  of  definite  objects  for  which  money  is 
needed,  and  this  is  now  ready  to  be  sent  out. 

Expressions  of  interest  in  the  Committee's  work  have  come 
from  many  sources.  Letters  of  inquiry  have  been  received 
from  various  parts  of  the  country  requesting  copies  of  the 
publications  of  the  Committee.  Some  come  from  State  com- 
missions and  societies  working  for  the  same  ends  as  this  Com- 
mittee; others  tell  piteous  stories  of  sons  or  husbands  sinking 
under  the  disease  and  beg  us,  if  we  have  any  sure  cure,  to  send 
it  at  once.  Still  others  read  something  like  this:  "Dear  Firm, 
I  saw  your  ad  in  the  evening  paper  a  few  days  ago  and  would 
like  to  know  more  about  it."  The  "ad  "  proves  to  be  a  quo- 
tation from  the  Health  Department  circular  to  the  effect  that 
more  information  may  be  obtained  either  there  or  at  this  office. 

One  part  of  its  educational  work  the  Committee  was  fairly 
forced  into  by  the  daring  expedients  of  the  "sure  cure"  con- 
cerns. Several  of  them  so  juggled  with  utterances  of  members 
of  the  Committee  and  with  statements  of  the  purposes  of  the 
Committee  as  to  create  the  impression  that  their  specifics  had 
the  sanction  of  the  Committee  and  of  the  Charity  Organiza- 
tion Society.  The  following  expression  of  opinion  on  this 
point  was  accordingly  published,  over  the  signatures  of  the 
entire  Committee: 

11 


"  Whereas,  It  has  come  to  the  knowledge  of  the  Committee 
on  Tuberculosis  of  the  Charity  Organization  Society  that  many 
so-called  specific  medicines  and  special  methods  of  cure  for 
tuberculosis  have  been  and  are  being  exploited  and  widely 
advertised,  and 

"  Whereas,  The  advertisements  of  some  of  these  cures  have 
made  such  reference  to  the  Tuberculosis  Committee  of  the 
Charity  Organization  Society,  or  to  some  of  its  members,  as 
to  create  the  inference  that  this  Committee,  or  its  members, 
recommend  or  advocate  the  use  of  many  such  so-called  specifics 
or  special  methods  of  cure  for  pulmonary  tuberculosis,  or  con- 
sumption, and 

"  Whereas,  There  is  no  specific  medicine  for  this  disease 
known,  and  the  so-called  cures  and  specifics  and  special  methods 
of  treatment  widely  advertised  in  the  daily  papers  are  in  the 
opinion  of  the  Committee  without  special  value,  and  do  not  at 
all  justify  the  extravagant  claims  made  for  them,  and  serve 
chiefly  to  enrich  the  promoters  at  the  expense  of  the  poor  and 
frequently  ignorant  or  credulous  consumptives,  Therefore, 

"Resolved,  That  a  public  announcement  be  made  that  it  is  the 
unanimous  opinion  of  the  members  of  this  Committee  that 
there  exists  no  specific  medicine  for  the  treatment  of  pulmonary 
tuberculosis,  and  that  no  cure  can  be  expected  from  any  kind 
of  medicine  or  method  except  the  regularly  accepted  treatment 
which  relies  mainly  upon  pure  air  and  nourishing  food." 

Five  thousand  copies  of  this  warning  were  issued.  They 
have  been  sent  to  all  the  clergymen  in  New  York  City,  to 
every  daily,  weekly,  and  monthly  paper  published  in  the  city, 
to  all  registered  nurses,  to  all  charitable  societies,  to  the  secre- 
taries of  every  county  medical  society  in  the  State  of  New 
York,  and  to  all  the  medical  societies  in  Greater  New  York. 
Copies  have  also  accompanied  each  package  of  pamphlets  sent 
to  offices  and  schools. 

The  library  of  the  Charity  Organization  Society  contains  a 
number  of  pamphlets  and  books  on  the  subject,  particularly 
its  social  aspects.      A  large  number  of  clippings  from  papers 

12 


all   over  the   country  has  been   accumulated,   bearing  on  the 
work  of  the  Committee  and  on  similar  work  elsewhere. 

A  bibliography  of  some  of  the  most  important  works  on 
tuberculosis,  in  English,  French,  and  German,  has  been  se- 
lected by  Dr.  S.  A.  Knopf  from  the  mass  of  such  literature, 
and  is  presented  in  Appendix  20. 

III. — REMEDIAL  AND  PREVENTIVE  MEASURES. 

Dispensaries  and  Sanatoria. — At  the  beginning  of  the  year's 
work  a  survey  was  made  of  existing  provisions  for  the  treat- 
ment of  poor  consumptives  in  New  York  City  (Appendix  18). 
Their  inadequacy  led  the  Committee  to  direct  a  considerable 
part  of  its  efforts  towards  investigating  and  encouraging  move- 
ments for  increasing  dispensary  facilities  and  sanatorium 
accommodations. 

A  year  ago  Dr.  Russell's  class  for  consumptives  at  the  Post- 
Graduate  Hospital,  the  class  at  St.  Bartholomew's  Clinic,  and 
the  Dispensary  class  of  the  New  York  Nose  and  Throat  Hos- 
pital were  the  only  satisfactory  attempts  being  made  to  provide 
proper  dispensary  treatment  for  ambulant  cases.  In  January 
a  special  class  for  consumptives  was  instituted  at  Vanderbilt 
Clinic,  under  the  direction  of  Dr.  James  A.  Miller  (Appendix 
17).  A  building  for  a  municipal  dispensary  is  now  being 
erected  on  the  lot  adjoining  the  building  of  the  Department  of 
Health  on  the  south,  and  the  expectation  is  that  it  will  be 
opened  in  January,  1904. 

The  possibilities  of  the  dispensary  in  dealing  with  the  tuber- 
culosis problem  cannot  be  exaggerated.  That  the  dispensaries 
of  the  city,  with  two  or  three  exceptions,  do  not  realize  their 
opportunities  is  a  fact  to  be  deplored, — and  faced.  With  a 
view  to  stimulating  interest  in  this  part  of  the  situation,  all 
the  larger  dispensaries  were  visited  by  representatives  of  the 
Committee,  who  consulted  with  the  officials'  in  regard  to 
the  possibility  of  special  treatment  for  consumptives.  Later 
the  presidents  of  the  boards  of  managers  of  all  the  dispensaries 
in  the  city  were  invited  to  send  delegates  to  a  conference  to  be 

13 


held  in  the  United  Charities  Building  to  discuss  the  advisability 
of  establishing  special  classes  for  tuberculous  patients,  one  for 
adults,  and  another  for  children,  in  the  dispensaries.  The  meet- 
ing was  held  on  March  31. 

The  work  now  being  done  at  Vanderbilt  Clinic  is  indicative 
of  the  tremendous  force  latent  in  machinery  already  existing, 
which  could  be  developed  at  comparatively  slight  expense. 
Its  success  has  led  to  the  initiation  of  similar  work  at  Mt.  Sinai 
Dispensary  in  New  York,  at  the  Yale  Dispensary  in  New 
Haven,  and  at  still  another  in  Rochester,  and  classes  are  to  be 
organized  soon  by  Dr.  Miller  at  Bellevue,  Harlem,  and  Gouver- 
neur  Hospitals  in  New  York  City. 

The  activity  of  the  Committee  in  relation  to  hospital  and 
sanatorium  provision  has  been  threefold. 

When  the  appropriation  for  completing  the  State  Hospital 
at  Raybrook  was  under  consideration,  and  it  was  uncertain 
whether  the  revenues  of  the  State  would  bear  the  expenditure 
of  the  full  amount,  the  following  letter  was  addressed  to  the 
Governor : 

"  April  22,  1903. 

"Hon.  B.  B.  Odell,  Jr.,  Governor, 
"Albany,  N.  Y. 

"Sir: 

"On  behalf  of  the  Charity  Organization  Society's  Committee 
on  the  Prevention  of  Tuberculosis,  I  am  authorized  to  write, 
earnestly  asking  executive  approval  of  the  appropriation  by 
the  Legislature  of  $115,000  for  the  completion  of  the  State 
Hospital  for  Incipient  Cases  of  Tuberculosis. 

"The  need  of  this  institution  is  very  great.  Its  usefulness 
at  present  and  in  the  immediate  future,  in  view  of  the  wide- 
spread interest  in  the  prevention  of  tuberculosis  and  the  public 
determination  to  make  such  measures  effective,  will  be  incal- 
culable. The  delays  in  the  selection  of  the  site  and  the  erection 
and  opening  of  the  hospital  since  its  establishment  was  first  de- 
termined upon,  are  most  unfortunate;  and  it  will  be  doubly 
unfortunate  if  less  than  the  full  amount  requisite  to  complete 
and  make  the  buildings  available  should  not  be  approved. 

14 


"I   am   requested   by   the    Committee    to    express,    in    the 
strongest  possible  manner,  their  hope  that  you  will  be  able  to 
approve  the  appropriation  as  passed  by  the  Legislature. 
"Respectfully  yours, 

"(Signed)     Edward  T.  Devine, 

"General  Secretary, 
"Charity  Organization  Society," 

By  the  approval  later  of  the  appropriation  in  full  the  danger 
of  any  further  delay  that  might  have  arisen  through  lack  of 
funds  was  averted. 

In  January  a  sub-committee  was  appointed  to  confer  with 
the  city  Department  of  Health,  to  urge  plans  for  the  erection 
of  a  municipal  sanatorium  and  to  offer  co-operation  in  regard 
to  ways  and  means.  Two  sets  of  plans  for  such  a  sanatorium 
were  prepared  for  the  Committee,  one  by  Messrs.  Renwick, 
Aspinwall,  &  Owen,  the  other  by  Messrs.  Howells  &  Stokes 
(Appendices  13  and  14). 

The  popular  sentiment  aroused  by  the  discussion  in  the  daily 
press  and  elsewhere  in  regard  to  the  necessity  for  a  municipal 
sanatorium  finally  found  expression  in  resolutions  adopted  by 
the  Board  of  Aldermen  on  April  14  calling  on  the  Commis- 
sioner of  Charities  to  prepare  a  report  on  the  subjecto  All  the 
pertinent  material  in  the  hands  of  the  Committee,  including 
both  sets  of  plans,  were  at  once  put  at  the  Commissioner's  dis- 
posal. In  his  report  of  July  15,  to  the  Board  of  Estimate 
and  Apportionment,  he  submitted  copies  of  both  sets  of 
sketches,  together  with  the  explanatory  letters  of  the  archi- 
tects, as  "suggestions  of  the  general  character  of  buildings  now 
favored  for  such  purposes." 

The  third  way  in  which  the  Committee  sought  to  use  its  in- 
fluence in  the  interests  of  sanatorium  and  hospital  provision 
was  by  protesting  and  arousing  protests  from  various  other 
organizations  and  individuals  against  the  Goodsell-Bedell  bill,  a 
bill  which  has  been  accurately  described  as  one  "to  discourage 
provision  for  poor  persons  suffering  trom  pulmonary  tuberculo- 
sis." The  bill,  which  has  since  become  a  law,  read  as  follows : 

15 


"A  hospital,  camp,  or  other  establishment  for  the  treatment 
of  patients  suffering  from  the  disease  known  as  pulmona'ry 
tuberculosis  shall  not  be  established  in  any  town  by  any  per- 
son, association,  corporation,  or  municipality,  unless  the  board 
of  supervisors  of  the  county  and  the  town  board  of  the  town 
shall  each  adopt  a  resolution  authorizing  the  establishment 
thereof,  and  describing  the  limits  of  the  locality  in  which  the 
same  may  be  established." 

The  protest  of  the  Committee,  as  such,  was  first  voiced  in 
the  following  letter  to  the  Governor : 

"April  22,  1903. 

"Hon.  B.  B.  Odell,  Jr.,  Governor, 

"Capitol,  Albany,  N.  Y. 
"Sir: 

"I  am  authorized  by  our  Committee  on  the  Prevention  of 
Tuberculosis  earnestly  to  request  your  disapproval  of  the 
Goodsell-Bedell  bill  (Assembly  Int.  No.  1247,  entitled  'An 
Act  to  Amend  the  Public  Health  Law  in  Relation  to  the  Estab- 
lishment of  Public  Hospitals  or  Camps  for  the  Treatment  of 
Pulmonary  Tuberculosis  '),  requiring  the  consent  of  township 
and  county  authorities  for  the  establishment  of  any  sanatorium 
for  consumptives  which,  under  authority  of  Chapter  327  of  the 
Laws  of  1900,  might  be  erected  by  a  city  of  the  first  class  out- 
side the  city  limits. 

"Under  the  act  above  mentioned,  it  is  necessary  to  secure 
the  consent  of  the  State  Board  of  Health  to  the  selection  of 
any  such  site,  and,  in  addition,  it  is  provided  that  the  institu- 
tion, when  erected,  shall  be  under  the  supervision  and  over- 
sight of  the  local  Board  of  Health.  To  require  in  addition  that 
both  township  and  county  authorities  shall  give  their  consent 
is,  of  course,  to  make  the  establishment  of  any  such  sanatorium 
as  is  contemplated  by  the  act  of  1900  practically  impossible, 
Private  property  rights  are  sufficiently  protected  by  general 
laws,  and  the  process  of  injunction  is  open,  in  case  it  can  be 
positively  shown  that  unwarranted  injury  would  be  inflicted 
by  the  establishment  of  a  hospital  on  a  particular  site.  The 
necessity  of  obtaining  the  consent  of  the  State  Board  of  Health 

16 


is  ample  guarantee  that  a  site  shall  not  be  selected  which  will 
threaten  or  unduly  expose  the  health  of  any  particular  neigh- 
borhood. The  law  already  provides  that  the  hospital  cannot 
be  erected  within  the  incorporated  limits  of  any  city  or  village. 

"Our  Committee  on  the  Prevention  of  Tuberculosis,  having 
in  mind  all  these  existing  safeguards,  most  earnestly  protests 
against  adding  such  burdensome  conditions  as  are  imposed  by 
this  bill,  and  invites  your  consideration  of  the  urgent  need  of 
additional  sanatoria — public  and  private,  State  and  municipal 
— a  need  so  great  that  those  who  interpose  needless  obstacles 
to  meeting  it  incur  the  gravest  responsibility.  The  Board  of 
Aldermen  of  the  City  of  New  York  last  week  unanimously 
passed  resolutions  calling  upon  the  Commissioner  of  Public 
Charities  to  make  an  estimate  of  the  cost  of  providing  a  hos- 
pital with  sufificient  accommodations  to  care  for  all  indigent 
consumptives  in  the  city.  This  is  only  one  more  evidence  of 
the  growing  recognition  of  the  necessity  for  public  action  in 
meeting  the  scourge  of  tuberculosis.  The  State  of  New  York 
has  many  localities  which,  in  elevation  and  in  climatic  con- 
dition, are  ideal  sites  for  such  institution,  and  which  are  not 
suf^ciently  near  any  considerable  body  of  people  to  be  in  any 
sense  a  public  nuisance.  To  close  all  of  these  sites  to  the  city 
of  New  York  except  on  condition  of  securing  the  consent  of  at 
least  three,  and  possibly  four,  independent  bodies,  would  be 
an  act  of  such  gross  injustice  and  so  contrary  to  sound  public 
policy  that  we  confidently  rely  upon  your  preventing  its  con- 
summation. 

"I  need  not  say  that  our  opposition  to  this  measure  is  not 
founded  upon  any  desire  upon  our  part  to  see  a  hospital 
established  on  any  particular  site,  such  as  the  site  at  Central 
Valley,  which  has  been  so  much  discussed  in  the  press  and 
elsewhere. 

"I  have  the  honor  to  be,  with  great  respect, 
"Yours  very  truly, 

"(Signed)    Edward  T.  Devine, 

"General  Secretary, 
"Charity  Organization  Society." 
17 


Later,  on  April  30,  a  request  was  preferred  for  a  public 
hearing  on  the  bill,  in  this  letter; 

'April  30,  1903. 

"Hon.  B.  B.  Odell,  Jr.,  Governor, 

"State  Capitol,  Albany,  N.  Y. 
"Sir: 

"Unless,  on  the  receipt  of  this  letter,  you  have  already  de- 
cided not  to  give  your  approval  to  the  bill  amending  the  health 
law  by  adding  to  it  a  section  to  be  known  as  Sec.  218a,  requiring 
town  and  county  consents  to  the  erection  of  any  sanatorium, 
hospital,  or  camp  for  the  care  of  consumptive  patients,  this 
Committee  requests  that  a  public  hearing  be  given  on  the  sub- 
ject. There  are  many  persons  and  charitable  agencies  who  are 
opposed  to  this  legislation  and  would  like  an  opportunity  to 
express  their  views,  in  case  there  is  a  probability  that  the  bill 
will  be  approved. 

"As  most  of  the  persons  who  are  most  actively  interested  in 
this  matter  will  be  in  attendance  on  the  National  Conference 
of  Charities  and  Correction  at  Atlanta,  May  6  to  12,  we 
should  like  to  have  this  hearing  not  earlier  than  May  15,  and 
would  prefer  that  it  should  be  not  earlier  than  May  20,  as 
there  are  some  who  will  not  be  able  to  return  before  that  date. 
"Respectfully  yours, 

"(Signed)         Edward  T.  Devine." 

The  hearing  was  not  arranged. 

Finally,  the  arguments  of  the  first  letter  were  re-enforced  as 
follows : 

"  May  15,  1903. 

"Hon.  B.  B.  Odell,  Jr.,  Governor, 

"Capitol,  Albany,  N.  Y. 
"Sir: 

"On  April  22  I  wrote  you,  at  the  request  of  our  Committee 
on  the  Prevention  of  Tuberculosis,  in  reference  to  the  Good- 
sell-Bedell  bill  entitled  'An  Act  to  Amend  the  Public  Health 
Law  in  Relation  to  the  Establishment  of  Public.  Hospitals  or 
Camps  for  the  Treatment  of  Tuberculosis.'  In  that  letter  at- 
tention was  called  especially  to  the  effect   of  this  proposed 

18 


legislation  in  limiting,  if  not  practically  destroying,  the  power 
conferred  on  cities  of  the  first  class  by  Chapter  327  of  the  Laws 
of  1900,  authorizing  them  to  establish  sanatoria  outside  the 
city  limits.  The  bill,  however,  goes  far  beyond  this,  and  would 
equally  interfere  with  any  hospital,  camp,  or  sanatorium  which 
might  otherwise  be  erected  by  a  private  philanthropist,  a  fra- 
ternal society,  or  any  other  association  or  corporation. 

"At  the  very  time  when  private  philanthropy  is  disposed  in- 
creasingly to  make  some  provisions  for  the  prevention  of  the 
scourge  of  tuberculosis,  a  measure  is  brought  forward  which 
might  accurately  be  termed  a  bill  to  discourage  private  or 
public  action  in  the  relief  of  sufferers  from  tuberculosis. 

"Experience  has  shown  that  in  the  neighborhood  of  sana- 
toria of  this  kind  the  prevalence  of  the  disease  and  the  number 
of  deaths  from  it  are  actually  less  than  in  other  communities. 
The  rigid  discipline  which  it  is  possible  to  maintain  in  and 
about  institutions  of  this  kind,  and  the  educational  work  which 
it  undertakes,  are  a  sufficient  explanation.  To  assume  that 
the  health  of  the  entire  county  is  at  stake  or  is  in  any  way 
threatened  by  the  establishment  of  a  sanatorium,  is  the  height 
of  absurdity  ;  and  it  is  almost  equally  absurd  to  anticipate  that 
conditions  throughout  the  township  will  be  changed  unfavora- 
bly by  the  selection  of  a  site  for  a  sanatorium  within  its  limits. 

"Our  Committee  has  not  taken  action  adverse  to  the  prin- 
ciple that  in  some  appropriate  manner  local  opinion  should  be 
considered  in  the  selection  of  a  site  for  either  a  public  or  private 
sanatorium  ;  the  State  Board  of  Health  might  appropriately  be 
given  a  veto  power,  if,  on  petition  from  the  locality  affected, 
it  is  shown  that  injury  is  likely  to  result.  To  pass  a  law,  how- 
ever, placing  upon  town  and  county  authorities  the  duty  of 
deciding  whether  or  not  a  sanatorium  is  to  be  created,  is  to  do 
incalculable  mischief  by  the  effect  of  such  a  law  upon  public 
opinion.  The  very  existence  of  such  a  statute  suggests  that 
adverse  action  by  the  county  or  township  authorities  is  called 
for.  What  county  or  township  board  would  be  so  unpatriotic 
or  so  recreant  to  the  interests  of  local  property  holders  as  to 
give  consent  to  the  selection  of  a  site  for  a  sanatorium,  when 

19 


there  is  no  interest  demanding  it  except  that  of  humanity,  and 
no  reason  for  favorable  action  except  the  quixotic  desire  to 
lessen  the  number  of  needless  deaths  and  to  stamp  out  disease? 
"The  measure  is  so  sweeping  and  places  so  great  obstacles 
in  the  way  of  effective  care  for  a  large  class  of  the  sick  who  are 
not  and  probably  cannot  be  admitted  to  general  hospitals,  that 
we  respectfully  urge  that  it  be  not  approved. 
"Sincerely  yours, 

"(Signed)         Edward  T.  Devine." 

In  spite  of  these  efforts  and  equally  vigorous  expressions  of 
opinion  from  various  members  of  the  medical  profession  all 
over  the  State  and  from  many  charitable  agencies,  the  bill  be- 
came a  law.  To  secure  the  use  of  any  site  for  a  New  York 
City  sanatorium,  therefore,  it  will  be  necessary  to  obtain  the 
consent,  after  it  has  been  chosen  by  the  Board  of  Health  of  this 
city,  of  the  Town  Board,  the  County  Board  of  Supervisors, 
the  State  Board  of  Health,  and  presumably  the  local  Board  of 
Health.  It  remains  to  be  seen  whether  this  multiplication  of 
the  consents  required  will  hamper  movements  for  sanatoria  as 
much  as  has  been  feared. 

Relief  Work. — In  October,  1902,  the  families  in  which  con- 
sumption was  the  main  cause  of  dependence  and  which  had 
been  under  the  care  of  the  Charity  Organization  Society 
through  its  eleven  District  Committees,  were  all  transferred 
to  the  care  of  the  Committee  on  the  Prevention  of  Tubercu- 
losis, who,  through  a  sub-committee  on  Treatment,  endeavored 
to  supervise  and  obtain  relief  for  these  cases  scattered  through- 
out the  whole  of  the  boroughs  of  Manhattan  and  the  Bronx. 
With  little  variation,  it  was  the  same  story  in  each  case — the 
chief  bread-winner,  out  of  work,  at  last  giving  way  to  the  con- 
sumption which  had  been  making  work  for  him  more  and  more 
difficult,  even  while  it  made  wages  which  might  buy  necessary 
food  and  decent  lodgings  more  than  ever  essential ;  in  the  last 
stages  of  his  disease  or  when  it  had  secured  such  a  hold  on  him 
that  nothing  but  careful  nursing  and  prolonged  rest  could  re- 
tard the  inevitable  result,  coming  to  this  Committee  and  asking 

20 


for  rent  and  coal  and  special  diet ;  often  going  to  the  dispensary 
and  taking  advice  on  proper  precautions  to  be  observed,  but 
only  rarely  going  to  the  hospitals,  where  alone  any  permanent 
improvement  might  be  expected.  Up  to  April,  two  hundred 
and  eleven  families  came  under  the  supervision  of  the  sub- 
committee and  its  agent  and  four  visitors,  at  which  time  the 
relief  provided  amounted  to  about  one  thousand  dollars  a 
month.  For  reasons  of  internal  administration,  it  seemed  bet- 
ter to  turn  this  work  again  into  the  hands  of  the  regular  dis- 
trict committees  and  their  agents  and  thus  to  draw,  to  a  greater 
extent  than  was  possible  for  one  central  committee,  on  various 
local  and  personal  sources  of  relief.  The  Committee  on  the 
Prevention  of  Tuberculosis  since  that  date  has  not  taken  direct 
responsibility  for  the  relief  of  particular  cases,  but  is  placing 
at  the  disposal  of  district  committees  whatever  information  it 
can  secure  as  an  aid  in  their  treatment  of  the  families  in  which 
there  is  one  or  more  tuberculous  patients  and  in  which  relief  is 
required. 

Protest  agamst  Proposed  Changes  m  the  Tenement  Hoiise 
Law. — When  modifications  of  the  Tenement  House  Law  were 
threatened  which  would  have  been  a  direct  menace  to  the 
health  of  the  tenement  dwellers,  the  Committee  did  what  it 
could  to  aid  in  preventing  the  changes.  The  following  reso- 
lutions were  adopted  and  a  copy  forwarded  to  the  chairman 
and  each  member  of  the  Senate  and  the  Assembly  Committee 
on  Cities: 

"  Whereas,  There  are  now  pending  in  the  Legislature  at 
Albany  a  number  of  bills  to  amend  the  Tenement  House  Law, 
and 

"  Whereas,  None  of  these  bills  are  designed  to  strengthen 
the  Law  and  to  provide  additional  safeguards  for  the  health 
and  welfare  of  tenants,  and 

"  Whereas,  Their  enactment  would  be  one  of  the  most  seri- 
ous backward  steps  that  have  ever  been  taken  in  the  housing 
of  the  working  people.  Therefore  be  it 

''Resolved,  That  the  Committee  on  the  Prevention  of  Tuber- 
culosis is  directly  and  fundamentally  concerned  in  the  defeat 

21 


of  these  measures ;  that  the  Committee  is  earnestly  opposed 
to  any  amendment  of  the  Tenement  House  Law  that  will  re- 
duce the  amount  of  light  and  air  available  for  the  occupants 
of  tenements,  whether  in  new  or  in  old  buildings.  Be  it 
further 

''Resolved,  That  the  Committee  is  especially  opposed  to  any 
modification  of  the  Law  which  will  permit  dark  and  semi-dark 
bedrooms  in  new  houses,  or  will  permit  a  return  to  the  old 
narrow,  dark,  unventilated  air-shaft  in  the  construction  of  new 
houses ;  or  any  change  in  the  Law  that  will  remove  from  the 
protection  of  the  present  Law,  houses  which  are  now,  by  the 
terms  of  the  Law,  included  within  its  provisions.  And  be  it 
further 

''Resolved,  That  the  active  assistance  of  all  who  wish  to 
check  the  ravages  of  tuberculosis  in  its  various  forms  is  asked 
in  defeating  any  bills  for  the  amendment  of  the  Tenement 
House  Law." 

Fortunately  public  opinion  was  sufificiently  strong  on  the 
same  side  to  prevent  the  proposed  amendments  from  becoming 
law. 

PLANS  FOR  THE  YEAR  I903-4. 

The  work  of  the  Committee  for  the  second  year  will  proceed 
along  the  same  general  lines.  A  repetition  of  its  fundamental 
principles  and  a  statement  of  the  most  urgent  needs  of  the 
city  at  this  stage  of  the  movement  to  check  tuberculosis  are 
embodied  in  the  second  appeal  for  funds,  which  reads  as 
follows : 

"In  order  to  check  the  ravages  of  consumption  in  New  York 
City,  concerted  action  by  the  government,  by  the  medical  pro- 
fession, relief  agencies,  and  private  citizens  is  necessary.  A 
municipal  sanatorium  for  patients  in  the  early  stages  of  the 
disease  and  a  municipal  dispensary  are  required.  Steps  have 
already  been  taken  toward  meeting  these  needs,  but  the  move- 
ments should  be  advanced  as  rapidly  as  possible  and  should  be 
heartily  encouraged  by  all  organs  of  public  opinion.  Further 
provision  by  the  city  for  the  exclusive  treatment  of  consump- 

22 


tives  in  the  later  stages  of  the  disease  is  urgently  needed, 
although  considerable  progress  has  been  made  in  this  direction. 
The  earliest  possible  completion  of  the  State  hospital  for  in- 
cipient cases,  at  Raybrook,  should  also  be  urged.  These  are 
the  most  obvious  undertakings  for  the  State  and  city  govern- 
ments. They  leave  much  responsibility  with  the  individual 
members  of  society. 

"Among  the  special  needs  which  will  have  to  be  supplied 
chiefly  by  private  initiative,  the  Committee  on  the  Prevention 
of  Tuberculosis  places  emphasis  at  the  present  time  on  the 
following : 

"i.  Private  sanatoria  should  be  provided  for  patients  who 
can  afford  to  pay  a  moderate  amount,  and  they  should  also  be 
endowed  sufficiently  to  provide  for  absolutely  free  treatment 
in  exceptional  cases.  Such  provision  as  is  now  made  in  the 
Adirondack  Cottage  Sanatorium,  the  Loomis  Sanatorium, 
Bedford  Branch  of  Montefiore  Home,  Gabriel's  Sanatorium, 
the  Stony  Wold  Sanatorium,  Seton  Hospital,  and  St.  Joseph's 
Hospital,  should  be  increased  either  by  the  creation  of  new 
institutions  or  by  adding  to  the  facilities  of  those  already  in 
existence. 

"2.  Relief  funds  should  be  supplied  for  the  relief  of  indigent 
consumptives  in  their  own  homes  until  sanatorium  or  hospital 
accommodations  are  provided,  and  for  patients  who,  on  com- 
petent medical  advice,  can  safely  and  with  advantage  to  them- 
selves and  their  neighbors  be  treated  at  home.  For  such 
patients  special  diet  is  essential,  including  ample  quantities  of 
milk  and  eggs  and  such  medicines  as  may  be  prescribed.  It  is 
often  essential,  also,  to  remove  the  family  into  lighter  and 
better  ventilated  rooms,  and  for  this  purpose  provision  for  the 
payment  of  rent  is  sometimes  necessary. 

"3.  There  are  some  instances  in  which  the  payment  of  board 
in  private  families  outside  the  city  is  advisable,  and  relief  funds 
should  be  provided  for  this  purpose,  especially  in  the  interval 
pending  the  enlargement  of  sanatorium  and  hospital  accom- 
modations. 

"4.    Special    dispensaries    or   clinics   for  the  treatment    of 

23 


patients  living  at  home  are  desirable.  The  presence  of  persons 
suffering  from  various  forms  of  tuberculosis  in  general  dis- 
pensaries is  objectionable  in  the  interests  both  of  themselves 
and  of  other  patients.  Beginnings  have  already  been  made  in 
this  direction,  and  the  Health  Department  is  about  to  open  a 
special  dispensary,  but  if  funds  are  provided  to  meet  the 
expense,  several  additional  dispensaries  would  make  special 
provision  of  this  kind,  and  the  out-patient  treatment  at  the 
dispensary  should  be  supplemented  by  the  provision  of  special 
diet,  when  necessary,  and  by  district  nursing. 

"5.  Seaside  sanatoria  for  scrofulous  and  tuberculous  children 
are  also  needed,  to  which  teachers  should  be  attached,  so  that 
the  intellectual  development  of  the  children  need  not  suffer. 

"6.  An  agricultural  colony  is  desirable,  where  cured  patients 
discharged  from  the  sanatoria  may  find  out-door  employment 
for  a  time.  They  will  thus  be  better  prepared  to  re-enter  their 
former  occupations  and  in  some  instances  may  have  learned  to 
like  farm-work  and  will  not  wish  to  return  to  the  overcrowded 
city.  A  horticultural  colony  might  be  established  with  the 
same  point  in  view. 

"7.  The  education  of  the  public  in  the  means  of  prevention, 
and  in  those  facts  concerning  the  cure  and  treatment  of  the 
disease  which  are  of  interest  and  of  value  to  the  general  public, 
is  one  of  the  essentials  to  the  stamping  out  of  the  disease. 
Public  lectures  by  physicians,  the  distribution  of  leaflets  pre- 
pared by  expert  authorities,  and  research  into  the  social 
aspects  of  the  disease,  have  been  undertaken  by  the  Committee 
on  the  Prevention  of  Tuberculosis,  and  funds  are  required  to 
carry  forward  these  undertakings. 

"Contributions  to  meet  any  of  the  above  needs  may  be  made 
through  the  Committee  on  the  Prevention  of  Tuberculosis. 
Careful  attention  will  be  given  to  any  requests  for  advice  or 
suggestions  from  any  who  are  willing  to  aid  this  movement  in 
whatever  manner." 


24 


FINANCIAL    REPORT    FOR    THE    YEAR    ENDING 

JUNE  30,    1903 

RECEIPTS 

Balance  on  hand  June  30,  1902 ^    700.00 

Contributions  and  subscriptions 7,355-oo     $8>o55-oo 

DISBURSEMENTS 

Salaries  and  wages , $3,024.64 

Printing  and  stationery 774-92 

Postage 262.00 

Illustrating  lectures i47-io 

Outfit 5  2.00 

Medical  supplies 66.37 

Petty  expenses 243.85     $4,570.88 

Balance  on  hand  June  30,  1903 $3,484.12 


CONTRIBUTIONS  FOR   GENERAL  WORK  OF   THE 

COMMITTEE  ON  THE  PREVENTION 

OF  TUBERCULOSIS 


JULY,    1902,    TO    JUNE,    1903 


Adriance,  Harris  Ely S 

10.00 

Aldrich,  Mrs.  James  Herman 

10.00 

Aldrich,  William  P 

10.00 

Amend,  Bernard  G 

25.00 

Anonymous  : 

A  Friend     i 

000  00 

"J.  M." 

5.00 

"H.  G.  K." 

25.00 

"I.  B.  C." 

2.00 

"  H.  D.  H." 

2.00 

Archbold,  John  D 

50.00 

Arnold,  Constable,  &  Co. . ,  . 

100.00 

Avery,  Samuel  P 

50.00 
100.00 

Bannard,  Otto  T 

Baylis,  Miss  Mary 

25.00 

Beckhard,  M 

Beekman,  Dr.  J.  N 

Bloomingdale,  J.  B 

Boissevain  &  Co 

Bonner,  George  T 

Brewster,  Mrs.  Benj 

Brewster,  Robert  S 

Buchtenkirch,  Herman  .  . .  . 

Calhoun,  Henry  W 

Carter,  Jas.  C 

Clark,  Miss  Ella  Mabel  .  .  . 
Claudwell,  Mrs.  Wm.  A. . . 
Claudwell,  Dr.  Charles  M. 

Cochran,  W.  Bourke 

Cole,  Mrs.  Hugh  L 


$20.00 
10.00 
25.00 
25.00 
20.00 
100.00 
100.00 
10.00 
50.00 
10.00 
25.00 
25.00 
25.00 
50.00 
10.00 


35 


Colgate,  William $20.00 

Comstock,     Mr.     and     Mrs. 

Albert 20.00 

Congdon,  H.  L 5.00 

Conger,  Henry  C 10.00 

Cox,  Chas.  F 100.00 

Cravath,  Mrs.  Paul  D 10.00 

Davis,  Mr.  and  Mrs.  Gherardi  50.00 

Bench,  Dr.  Edward  B 10.00 

DeVinne,  Theo.  L 10.00 

DeWitt,  George  G 25.00 

Drummond,  Mrs.  Jas.  F 5.00 

Durkee,  E.  R.,  &Co 10.00 

Eidlitz,  Marc,  &  Son 25.00 

Eidlitz,  Otto  M 10.00 

Ellis,  George  W 10.00 

Fahnestock,  H.  C 100.00 

Fischer,  B. ,  &  Co 25.00 

Frothingham,  H.  P 10.00 

Goddard,  J.  W.,  &  Sons 50.00 

Goldenkranz,  Dr.  S 5.00 

Gottheil,  Paul 25.00 

Gurnee,  A.  C 10.00 

Gutta  -  Percha    and     Rubber 

M'f'g  Co 25.00 

Hall,  Mrs.  John  H.,  Sr 10.00 

Harkness,  Edward  S. . .    .    . .  50.00 

Harkness,  Mrs.  S.  V 50.00 

Head,  Charles,  &  Co 25.00 

Hearn,  Arthur  H 25.00 

Heimann  &  Lichten 10.00 

Henderson,  Miss  Mary  W.  . .  5.00 

Herrman,  Mrs.  Esther 10.00 

Hoyt,  Mrs.  Colgate 10.00 

Hubbard,  Thos.  H 50.00 

Humphreys,  Alex.  C 10.00 

Hyatt,  A.  M 15.00 

Isham,  Samuel 10.00 

Isham,  Wm.  B 25.00 

Isham,   Mrs.  Wm.  B 25.00 

James,  Dr.  Walter  B 50.00 

Jennings,  Frederic  B 50.00 

Jennings,  Mrs,  Walter 200.00 

Kaufman,  Irma  L i.oo 

Kemeys,  Mrs.  Walter  S 10.00 

Kennedy,  William  L 10.00 


Kohnstamm,  Emil  V $50.00 

Koven,  L.  O.,  &  Brother. . . .  10.00 

Krotel,  Rev.  G.  F.,  D.D 10.00 

Laidlaw,  Jas.  L 100.00 

Lawrence,  Cyrus  J 10.00 

Lazarus,  Mrs.  Amelia  B 10.00 

Lee,  Mrs.  Frederic  S 50.00 

Leeds,  Mrs.  William  B 50.00 

Lisman,  F.  J 50.00 

Loomis,  Dr.  Henry  P. 25.00 

McMahon,  M.  T 10.00 

McKesson,  John,  Jr 100.00 

McKinn,  John  A 25.00 

MacLaren,  Mrs.  F 10.00 

Manierre  &  Manierre 5.00 

Mason,  William 10.00 

Martin,  Mrs.  John 5.00 

Metropolitan  Tobacco  Co. . . .  25.00 

Milliken,  E.  F 25.00 

Moore  &  Schley 25.00 

Morgan,  Miss  Caroline  L. . . .  100.00 

Munn,  Charles  A 5.00 

Munn,  O.  D 20.00 

Oelrichs  &  Co 50.00 

Ogden,  Robert  C 25.00 

Olyphant,  J.  Kensett 10.00 

Oppenheimer,  Dr.  Henry  S. .  10.00 

Park  &  Tilford 100.00 

Parsons,  John  E 20.00 

Passavant  &  Co 10.00 

Peaslee,  Dr.  Edward  H 10.00 

Penfold,  William  Hall 50.00 

Pinkerton,  Robert  A 10.00 

Poel,  F 50.00 

Price,  Mrs.  J.  M 5,00 

Prosser,  Thos.,  &  Son 25.00 

Rand,  Charles  F 10.00 

Rathbone,  R.  C 25.00 

Read,  William  A 50.00 

Redmond,  Miss  Emily 20.00 

Redmond,  G.  H 25.00 

Ripley,  Louis  A 10.00 

Robertson,  Albert 10.00 

Rockefeller,  John  D 1,500.00 

Rogers,  Edward  L 25.00 

Rubino,  Jacob 100.00 


26 


Sachs,  Mrs.  Samuel $10.00 

Sackett,  Henry  W 5.00 

Schenck,  Miss  A.  H 10.00 

'  Schermerhorn,  Wm.  C 250.00 

Schiff,  Jacob  H 250.00 

Schiff,  Mortimer  L 100.00 

Seligman,  Isaac  N 100.00 

10.00 

10.00 

5.00 

10.00 

5.00 

25.00 

10.00 

25.00 

50.00 

10.00 

5-00 

25.00 

10.00 

25.00 


Sidenberg,  G 

Sloan,  Benson  B 

Smith,  Henry  A   

Solomon,  Henry 

Sommers,  Miss  Clara. . . 

Starr,  Dr.  M.  Allen 

Stein,  Mrs.  A 

Sternbach,  Charles 

Stetson,  Francis  Lynde. 

Strauss,  Frederick 

Tappin,  Mrs.  John  C . . 

Tesla,  Nikola..-. 

Thacher,  Alfred  B 

Thacher,  Thos 


Thompson,  Mrs.  Walter  L. .  . 

Thome,  W.  V.  S 

Tiemann,  Julius  W 

Tiffany  &  Co 

Van  Winkle,  Miss  Mary  D. . . 

Wadsvvorth,  C.  S 

Wasserman  Bros 

Watson,  Porter,  Giles,  &  Co. 

Webb,  Mrs.  H.  Walter 

Weed,  Benj 

Weinberg,   Perry  A 

Wetmore,  Charles  W 

Wetmore,  Dr.  John  McE 

Wheeler,  Everett  P 

White,  G.  B 

Whitehouse,  Mrs.  J.  H 

Whitely,  James 

Willcox,  William  G 

Wills,  Charles  T 

Wurts,  Pierre  J. 

Younker,  Herman , 


I20.00 
10.00 

5.00 
50.00 
10.00 
10.00 
100.00 
10.00 
10.00 
10.00 

5.00 
25.00 

5.00 

5.00 
10.00 
10.00 
25.00 
25.00 
25.00 

5.00 
10.00 


CONTRIBUTIONS   FOR   RELIEF   WORK 


Anonymous  : 

In   memory   of    Graham 

M.  Leupp $100.00 

"  M," 5.00 

"A.  W.  M." 2.00 

Cash 2.00 

Cash .50 

Almond,  Mr.  and  Mrs.  T.  R.  10.00 

Benjamin,  John 10.00 

Bloodgood,  J.  H 50.00 

Close,  Miss  F.  H ,  7.00 

Cram,  Miss  E.  L 15.00 

Dexter,  Henry 100.00 


Duryee,  Miss  Alice $5.00 

Fitch,  Miss  Lucy  A 5.00 

Hickson,  Miss  J i.oo 

Higgins,  Mrs.  Arthur  S 5.00 

Hunter,  Miss  Anna  F i.oo 

Lederer,  Miss 10.00 

McKinn,  LeRoy 5.00 

Miller,  Miss  Sarah  M 5.00 

Morgan,  Geo.  F 1,000.00 

Robertson,  Albert 25.00 

Shumand,  Miss  L.  F 3.00 

Stone,  Miss  Annie 500.00 

Warburton,  F.  J 100.00 


'  Deceased. 


37 


Appendix  i 

THE   SOCIAL   ASPECTS    OF 

TUBERCULOSIS 

BASED  ON  A  STUDY  OF  STATISTICS 

By  LILIAN  BRANDT 


29 


THE   SOCIAL   ASPECTS   OF   TUBERCULOSIS 
BASED   ON   A   STUDY    OF   STATISTICS 

I 

PURPOSE  OF  THE  STATISTICAL  INVESTIGATION 

When  a  British  traveller,  some  decades  since,  wrote  to  a 
Turkish  host,  after  his  return  home,  asking  for  some  figures 
about  the  population  and  industries  of  the  town  he  had  visited, 
he  was  told  that  the  thing  he  asked  was  "  both  difificult  and 
useless."  The  Turk  saw  in  the  occasion,  also,  a  fitting  mo- 
ment for  a  general  criticism,  from  the  serene  heights  of  Islam 
philosophy,  of  the  disposition  of  the  European  mind  to  inquire 
into  matters  which  concern  it  not.  "Shall  we  say,"  he  asked 
his  friend,  by  way  of  illustrating  the  curiosity  he  deprecated, 
"  Behold,  this  star  spinneth  around  this  other  star,  and  this 
other  star,  with  a  tail,  cometh  and  goeth  in  so  many  years  ? 
Let  it  go.  He  from  whose  hand  it  came  will  direct  and  guide 
it." 

The  incident  has  a  double  application  to  a  study  of  tubercu- 
losis based  on  statistics.  There  are  not  lacking  among  us  ob- 
jectors to  the  statistical  method  of  increasing  knowledge  on 
the  ground  that  it  is  "  both  difficult  and  useless,"  and  until 
recently  the  popular  attitude  toward  tuberculosis  has  been 
analogous  to  that  of  the  Turkish  letter-writer  toward  the 
transactions  of  the  heavenly  bodies. 

It  is  only  twenty  years  since  the  revelations  of  the  micro- 
scope despoiled  us  of  our  justification  for  maintaining  this 
Oriental  habit  of  mind  on  the  subject  of  tuberculosis.     The 

31 


establishment  of  the  fact  that  consumption  is  not  hereditary 
has  taken  it  out  of  the  Hst  of  things  about  which  inquiry  is 
unprofitable ;  the  demonstration  that  it  is  curable  and  prevent- 
able has  put  it  into  the  list  of  evils  for  which  man  can  no 
longer  on  any  plausible  pretext  shirk  a  share  of  responsibility. 

In  regard  to  the  statistical  method,  we  agree  with  the  Turk 
that  it  is  "difficult,"  but  we  deny  that  it  is  "useless."  Prob- 
ably an  imperfect  realization  of  its  difficulty  has  prevented  its 
value  from  being  recognized.  For  it  must  be  admitted  that 
the  illegitimate  use  often  made  of  it,  either  by  the  guileless 
who  have  faith  in  the  tradition  that  figures  are  incapable  of 
deception,  or  by  the  unscrupulous  who  exploit  for  their  own 
ends  the  common  acceptance  of  this  tradition,  is  enough  to 
warrant  its  being  discredited.  The  statistical  method  has  its 
limitations,  but  it  has  also  its  value.  It  might  be  said  that  the 
latter  is  directly  proportional  to  the  clearness  with  which  its 
limitations  are  defined. 

It  is  the  purpose  of  this  report  to  make  available  for  applica- 
tion to  the  problem  of  preventing  tuberculosis  the  statistics 
which  reveal  its  social  relations.  To  this  end  only  such  statis- 
tics are  presented  as  are  pertinent  to  the  practical  issue;  in 
compiling  the  tables  the  aim  has  been  to  make  them  no  more 
numerous  or  complicated  than  is  compatible  with  giving  all 
the  data  essential  to  an  understanding  of  their  significance ; 
the  most  important  tables  have  been  translated  into  diagrams 
or  maps  in  the  hope  that  the  graphic  form  may  prove  readable 
to  "those  who  run  "  ;  the  accompanying  text  is  an  attempt  to 
state  what  the  statistics  show  and  what  they  do  not  show; 
finally,  some  suggestions  are  made  for  the  practical  use  of  the 
facts  established  by  the  figures. 

It  will  be  seen  from  the  analysis  of  the  statistics  that  tuber- 
culosis is  of  social  significance.  It  is  a  social  problem  in  several 
senses.  The  position  it  holds  at  the  head  of  the  column  of 
death-dealing  diseases  makes  it  a  matter  of  grave  concern  to 
all  members  of  society ;  its  prevalence  depends  largely  on 
social  conditions;  in  turn  it  aggravates  social  evils;  and  its 
practical  eradication  rests  with  social  activity. 

32 


II 

IMPORTANCE  OF  COxNSUMPTION  AS  A  CAUSE  OF  DEATH 

The  statement  that  consumption  causes  more  deaths  than 
any  other  disease  has  been  so  freely  used  for  emphasizing  the 
necessity  of  doing  something  about  it  that  this  item  has  doubt- 
less become  common  property.  One-tenth  of  all  deaths  in  the 
United  States  are  due  to  this  cause;  in  the  large  cities  the 
proportion  ranges  from  seven  to  fifteen  per  cent. 

It  is  less  generally  known  that  this  pre-eminence  of  con- 
sumption is  being  vigorously  contested  by  pneumonia,  with 
the  prospect  that  the  next  Federal  Census  will  see  the  title  of 
"Captain  of  the  Men  of  Death"  transferred  to  the  aspiring 
rival.  The  Census  of  1900  showed  that,  while  for  the  whole 
United  States,  as  has  been  said,  consumption  was  still  in  the 
lead,  in  the  "registration  area"  '  it  had  already  dropped  be- 
hind. How  far  this  change  in  relative  position  is  due  to  inac- 
curate reporting  of  the  cause  of  death  cannot  be  measured. 
The  conviction  is  not  to  be  escaped  that  some  part  of  the  mor- 
tality due  to  consumption  is  attributed  to  pneumonia  and 
bronchitis.  Paradoxically  enough,  it  is  in  the  "registration 
area,"  where  the  vital  statistics  are  on  the  whole  more  reliable 
than  for  the  country  at  large,  that  this  particular  error  is  most 
likely  to  exist. 

Under  ordinary  circumstances,  where  there  is  no  considera- 
tion which  would  make  it  less  desirable  that  one  disease  should 


'  In  the  presentation  of  results  in  the  Federal  Census  those  States  and  cities 
whose  registration  records  gave  evidence  of  being  the  most  nearly  complete  were 
classed  together  as  the  registration  area.  The  total  population  of  the  registration 
area  amounted  to  thirty-eight  per  cent  of  the  population  of  the  United  States. 
It  comprised  the  States  of  Connecticut,  Maine,  Massachusetts,  Michigan,  New 
Hampshire,  New  Jersey,  New  York,  Rhode  Island,  Vermont,  and  the  District  of 
Columbia,  and  included  so  many  of  the  important  cities  throughout  the  country 
that  it  may  be  considered  fairly  typical.  It  is  probable  that  the  superior  accuracy 
of  the  returns  from  this  area  makes  them  ordinarily  more  truly  indicative  of  the 
country  as  a  whole  than  are  the  defective  returns  given  for  the  whole  United 
States. 

33 


be  assigned  as  a  cause  of  death  than  another,  the  probabiHty 
is  that  the  importance  of  consumption  in  the  mortality  records 
is  exaggerated.  Any  illness  accompanied  by  the  well-known 
signs  of  consumption,  emaciation  and  a  cough,  if  it  is  not 
clearly  something  else,  is  naturally  believed  to  be  this  familiar 
disease ;  and  it  may  well  be  that  in  those  parts  of  the  country 
where  competent  medical  judgment  is  limited  in  supply,  the 
number  of  deaths  due  to  consumption  is  over-stated. 

In  the  registration  area,  not  only  is  this  source  of  error  elimi- 
nated by  the  higher  average  and  more  plentiful  distribution  of 
medical  knowledge,  but  there  exist  considerations  which  tend 
to  bring  the  registration  of  deaths  from  consumption  below 
their  actual  number.  There  are  doctors,  in  cities  where  in- 
spection and  disinfection  are  the  rule  after  a  death  from  tuber- 
culosis, who  can  be  persuaded  to  report  the  death  as  due  to 
chronic  bronchitis  or  pneumonia,  in  order  that  the  family  may 
be  saved  the  discomfort  of  an  enforcement  of  the  regulation. 
Presumably  they  justify  to  themselves  their  mis-statement  of 
the  fact  and  their  evasion  of  a  desirable  sanitary  requirement, 
by  seeing  personally  that  the  proper  precautions  are  taken  and 
the  necessary  renovation  done.  Another  circumstance  which 
has  still  more  influence  in  this  direction  is  the  practice  of  some 
small  mutual-benefit  societies,  to  refuse  to  pay  claims  when 
the  death  is  due  to  tuberculosis.'  It  is  not  strange  that  to 
the  physician  in  such  cases  the  accuracy  of  vital  statistics  often 
seems  a  remote  concern  by  comparison  with  the  immediate 
needs  of  the  family  in  which  he  is  interested.  The  ethics 
of  the  question  does  not  allow  of  debate,  but  it  is  of  less  in- 
terest in  this  connection  than  the  practical  result  that  the 
importance  of  consumption  as  a  cause  of  mortality  in  the 
registration  area  is  not  fully  represented  by  the  figures. 

As  neither  this  error  nor  the  one  which  affects  in  the  oppo- 
site direction  the  records  in  the  more  sparsely  settled  parts  of 
the  country  is  susceptible  of  mathematical  measurement,  it 
would  be  indiscreet  to  venture  an  estimate  as  to  how  far  they 

*  This  is  not  true  of  any  of  the  large  industrial  insurance  companies,  though  the 
impression  that  it  is  may  be  met  with. 

34 


supplement  each  other.  It  is  safe  to  say  that  in  the  combined 
figures  for  the  whole  country  the  tendency  to  under-statement 
in  the  registration  area  and  the  tendency  to  exaggeration  in 
the  non-registration  area  must  to  some  extent  counteract  each 
other,  so  that  on  this  particular  point  of  the  proportion  of 
deaths  due  to  consumption,  the  percentage  for  the  country  at 
large  is  probably  nearer  the  truth  than  that  for  either  of  its 
divisions.  Pneumonia,  moreover,  as  a  cause  of  death,  repre- 
sents many,  different  types  of  infection — not  a  single  one  as 
is  the  case  with  tuberculosis.  Different  cases  of  pneumonia 
show  different  changes  in  the  lungs  and  are  caused  by  different 
kinds  of  bacteria.  The  resemblance  often  rests  solely  in  the 
organ  of  the  body  attacked.  The  name  stands,  therefore,  for 
a  group  of  diseases  rather  than  for  a  single  one. 

It  will  be  seen,  also,  a  little  farther  on,  that  the  importance 
of  tuberculosis  as  a  social  phenomenon  does  not  rest  wholly, 
nor  even  chiefly,  on  its  claim,  now  likely  to  be  more  and  more 
disputed,  of  causing  the  largest  number  of  deaths,  but  rather 
on  the  discrimination  with  which  it  selects  its  victims  and  on 
its  intimate  causal  relation  to  many  social  problems.  The 
passing  of  its  day  of  glory  at  the  head  of  the  list  of  causes  of 
death  will  not  relieve  society  of  reasons  for  concern. 

Ill 

SOCIAL  FACTORS  IN  THE  PREVALENXE  OF  TUBERCULOSIS 

There  is  no  feature  in  the  composition  of  a  population  which 
does  not  affect  the  prevalence  of  consumption.  The  natural 
characteristics  of  age  and  sex  and  the  proportions  of  married 
and  single,  are  of  no  less  importance  in  explaining  the  death- 
rate  from  this  cause  in  any  locality  than  are  the  more  artificial 
factors  of  density  of  population,  housing  conditions,  occupa- 
tion, and  social  customs.  These  factors  form  a  complexus  so 
intimate  that  it  would  be  unprofitable  to  seek  to  indicate  the 
exact  influence  of  any  one  of  them  on  the  death-rate, —  to  say, 
for  example,  that  such  a  per  cent  of  the  loss  of  life  from  this 

35 


disease  in  New  York  City  is  attributable  to  insanitary  tene- 
ments, such  another  per  cent  to  intemperance,  and  so  on 
through  the  list.  It  is  even  found  impossible  to  arrange  the 
various  factors  in  a  logical  development  from  the  simple  to 
the  complex,  whereby  the  necessity  for  anticipation  might  be 
avoided.  After  leaving  the  variations  according  to  age  and 
sex,  the  explanations  and  reservations  are  often  perforce  based 
on  assumptions  for  which  evidence  is  produced  later  on.  Such 
a  system  of  cross  reference  calls  for  this  much  of  apology. 

SEX  AND  AGE 

This  disease  does  not  fall  with  equal  severity  on  men  and 
women  nor  on  all  ages. 

In  the  registration  area  of  the  United  States  in  1900  the 
consumption  death-rate  of  males  was  considerably  higher 
than  that  of  females.     (Table  i.) 

Table  i. — Mortality  in  the  Registration  Area  of  the  United  States, 
igoo,  BY  Sex. 


Total 
,  Popula- 
tion 

Deaths  from 
ALL  Causes 

Deaths  from 
Consumption 

Proportion  of 

Sex 

Num- 
ber 

Rate 
per 
1000 

living 

Num- 
ber 

Rate 

per 

1000 

living 

Deaths  from 
Consumption 

Males 

Females 

14,393,332 
14,413.937 

272,819 
239,850 

18.94 
16.64 

29,192 
24,770 

2.03 
1.72 

10.7^ 
10.3^ 

But  the  general  death-rate  is  always  higher  for  males  than 
for  females,  and  the  causes  of  this  difference  may  account  for 
a  large  part  of  the  difference  in  the  consumption  death-rate. 
That  they  do  not  account  for  the  whole  of  it  is  seen  in  a  com- 
parison of  the  proportion  of  deaths  caused  by  consumption; 

36 


for  tuberculosis  causes  10.7  per  cent  of  all  deaths  among 
males,  but  only  10.3  per  cent  among  females.  The  disparity 
is  still  greater  in  New  York  City,  where  the  proportion  is 
thirteen  per  cent  for  men,  but  less  than  ten  per  cent  for  women. 

This  fact — that  the  mortality  from  consumption  is  greater 
among  males  than  among  females  —  must  not  be  lost  sight 
of  in  considering  the  relation  of  age,  race,  occupation,  and 
geographical  distribution  to  the  disease. 

The  incidence  of  consumption  in  regard  to  age  is  shown,  for 
the  United  States,  in  Table  2,  which  gives  the  death-rates 
from  all  causes  and  from  consumption — that  is,  the  number 
of  persons  who  died  during  the  year  1900  out  of  each  1000 
persons  living  of  the  same  age  and  sex.  In  the  last  two  col- 
umns is  given  the  proportion  of  all  deaths  due  to  consumption. 

Table  2. — Mortality  in  the  Registration  Area  of  the  United  States. 
I  goo,  BY  Sex  and  Age 


Death  Rate  per  iooo  Living 

Proportion 

Caused  by 

Consumption 

Age  Periods 

All  Causes 

Consumption 

Male 

Female 

Male 

Female 

Male 

Female 

All  Ages 

18.9 

16.6 

2.0 

1.7 

10.7^ 

10.3% 

Under  5  years 

5-14  years 

15-24  years 

25-34  years 

35-44  years 

45-64  years 

65  and  over 

56.7 

4.4 

6.7 

9-5 

12.4 

24.1 

91. 1 

47-5 
4.2 
6.1 

8.5 
10.5 
20.1 
82.6 

0.7 
0.2 
1-9 
3-1 
3.0 
2.9 
2.9 

0.6 

0.3 
2.1 
2.8 
2.2 
1.7 
2.3 

1-3 
4.0 
28.7 
32.5 
24-3 
12.0 

3-2 

1.3 

7.8 

34.8 

33-1 

21. 1 

8.6 

2.8 

The  consumption  death-rate  is  greatest  for  both  men  and 
women  at  ages  over  twenty-five.  Evidently  this  alone  does 
not  indicate  the  relative  importance  of  the  disease  as  a  cause 
of  death.  For  example,  although  the  death-rate  from  con- 
sumption for  men  is  almost  twice  as  great  at  sixty-five  years 

37 


of  age  and  over  as  it  is  between  fifteen  and  twenty-four,  still 
the  second  rate  represents  28.7  per  cent  of  all  deaths  at  that 
age,  while  the  higher  rate  represents  only  3.2  per  cent  of  all 
deaths  among  old  men.  Similarly,  at  the  ages  twenty-five 
to  thirty-four  the  death-rate  from  consumption  is  greater 
among  men  than  among  women,  but  it  amounts  to  a  larger 
percentage  of  the  total  mortality  of  women  than  of  men. 

Among  men  consumption  causes  the  greatest  proportion 
of  deaths  between  twenty-five  and  thirty-four  years ;  among 
women,  between  fifteen  and  twenty-four.  Among  both  men 
and  women  it  works  its  greatest  havoc  in  early  middle  age,  be- 
tween the  ages  of  fifteen  and  forty-four,  when  it  causes  about 
one-third  of  all  the  deaths  that  occur. 

The  next  two  tables  (3  and  4)  give  the  same  facts  about  New 
York  City,  and  show,  in  addition,  the  distribution  of  other 
tubercular  diseases  than  consumption.  The  first  of  these  tables, 
expressed  in  graphic  form  by  Diagram  I.,  shows  the  relation  of 
deaths  from  consumption  and  from  all  tubercular  diseases  to 
the  population;  the  second,  with  Diagram  II.,  gives,  what  is 
more  significant,  their  relation  to  the  total  number  of  deaths. 


Table  3.- 


-MORTALITY  FROM  TUBERCULOSIS  IN  NeW  YORK  CITY,   IQOO,   BY  AGE 

AND  Sex 


Mortality  from  Phthisis 

Mortality  from  all  Tuber- 
cular Diseases 

Age 

Population 

Number 

Rate  per  100,000 
Living 

Number 

Rate  per  100,000 
Living 

"3 

s 

1 

"3 
g 

— 

"a 

s 

1) 

1 

"(3 
S 

Under  5 
5-9 
10-14 

15-19 
20-24 

25-34 
35-44 
45-54 
55-64 
65  and  over 

199,683 
177,591 
149,906 
140,670 
i6i,q88 
343,175 
261,095 
146,495 
78,692 
42,714 

197,604 
177,156 
151,358 
162,081 
192,853 
338,175 
232,950 

141,837 
82,591 
53,149 

"5 

23 

26 

182 

495 

1,552 

1,279 

738 

356 

196 

74 
29 

216 
456 
1,128 
658 
285 
182 
"5 

57 
12 

17 

129 
305 
452 
4S9 
503 
452 
458 

59 

95 
34 
38 
58 
27 
86 
77 
39 
87 

37-45 
16.37 
32.37 
133-27 
236.45 
333-56 
282.46 
200.93 
220.36 
216.37 

610 
86 

50 
201 

527 
1,628 
1,340 
767 
365 
209 

463 
78 
8i 
238 
487 
1,179 
698 
307 
193 
123 

305.48 
48-43 
33-35 
142.89 
325-33 
474-39 
513-22 
523-57 
463-85 
489.30 

234-37 
44-03 
53-52 
146.84 
252.52 
348.64 
299.64 
216.43 
232-34 
231-43 

38 


?<- 


ic 


^ 

^ 


^ 


lo 
'^ 


5*. 

is 


1 


fe 


I 


^ 
^ 


^ 

^ 


>- 


IS 


:s 


39 


Table  4. 


-Proportion  of  Mortality  Caused  by  Consumption  and  by  all 
Tubercular  Diseases  in  New  York  City,  igoo 


Males 

Females 

Number  of  Deaths 

Percentage 

Number  of  Deaths 

Percentage 

Age 

0) 

nj 

w 

"3  „ 

"  rt 

S  « 

-- 

S2 

^  s 

J2 

.Q   OJ 

^ 

£ 

^    <U 

3 

.i2 

-S  « 

u 

j: 

i^Q 

U 

^ 

t-'O 

0 

X 

hq 

0 

rC 

^0 

i— • 

:r5 

^ 

^2 

^ 

J3 

<c 

a, 

< 

< 

&( 

<« 

<: 

(^ 

< 

< 

Ph 

< 

Under  5 

14,006 

"5 

610 

100.00 

0.82 

4..36 

11,830 

74 

463 

100.00 

0.63 

3-91 

5-9 

1,046 

23 

86 

100.00 

2.20 

8.22 

t,027 

29 

78 

100.00 

2 

82 

7.00 

10-14 

431 

26 

50 

100.00 

6.03 

11.60 

432 

49 

81 

100.00 

II 

34 

18.7s 

15-19 

677 

182 

201 

100. CO 

26.88 

29.69 

712 

216 

238 

100.00 

.30 

34 

33-43 

20-24 

1,360 

495 

527 

100.00 

36.40 

38.75 

1,343 

456 

487 

100.00 

33 

95 

36.26 

25-34 

4^095 

1,552 

1,628 

100.00 

37-9° 

39.76 

3,297 

1,128 

1,179 

100.00 

34 

21 

35.76 

35-44 

4,527 

1,279 

1,^40 

ICO.OO 

28.25 

29.60 

3,080 

658 

698 

100.00 

21 

3b 

22.66 

45-54 

3i95i 

73a 

7f7 

100,00 

i8.63 

19.41 

2,937 

285 

307 

100.00 

9 

73 

10.45 

55-64 

3,398 

356 

365 

100.00 

10.48 

10.74 

3,166 

182 

193 

100.00 

5 

75 

6.10 

65  and  over 

4,487 

196 

209 

100.00 

4-37 

4.66 

5,070 

IIS 

123 

100.00 

2.27 

2-43 

iPm 


4(u.'&"Miisa^iX4  ^  9^u<rl^. 


■W 


^i% 

Ms 

c 

H 

^-9 

[    /M 

10 -IH- 

!■ 

l^-H 

;'';H^^H^H|H 

1 

SO-S^ 

11             1             1 

sr-dv 

n 

-  1             1             I 

d^-¥^ 

.AHI^HIHHh 

H 

^_L_J 

u^.^y 

■IHH 

1 

^^'i¥ 



/07, 

■1 

/Of, 


Diagram  II 
40 


Vef, 


These  tables  confirm  the  facts  already  noticed  in  regard 
to  pulmonary  tuberculosis :  that  it  is  a  comparatively  in- 
significant factor  in  the  loss  of  life  under  ten  years  of  age, 
that  its  importance  culminates  in  the  middle  age-periods, 
and  diminishes  after  forty-five.  They  show  also  that  other 
tubercular  diseases,  in  contrast,  are  of  chief  importance  in 
infancy  and  childhood.  Such  diseases — for  example,  tuber- 
culosis of  the  bones  and  glands  —  are  not  a  considerable 
danger  to  others,  but  they  are  of  significance  as  indicating  that 
consumption,  by  supplying  the  source  of  infection,  materially 
affects  the  well-being  of  children  although  it  is  not  prevalent 
among  them. 

The  next  diagram  (HI.)  brings  out  still  more  emphatically 
the  point  of  interest.  The  two  upper  circles  represent  the 
mortality  among  men  between  the  ages  of  twenty  and  thirty, 
and  between  the  ages  of  thirty  and  forty-five ;  the  two  lower 
ones,  that  of  women  in  the  same  age-groups.  In  each  circle 
the  black  segment  indicates  the  proportion  of  mortality  due 
to  consumption.  It  is,  to  say  the  least,  a  sobering  reflection 
that  over  a  third  of  all  the  men  who  die  between  the  ages  of 
twenty  and  thirty  die  from  a  preventable  disease. 

Another  method  of  showing  that  this  is  a  disease  of  the 
early  middle  years  is  by  the  average  age  at  death.  Omitting 
deaths  under  fifteen  years  of  age  from  the  calculation  for 
obvious  reasons,  it  is  found  that  the  average  age  in  1900  of 
persons  dying  from  all  causes  was  52.8,  but  of  those  dying 
from  consumption,  only  37.4  years.  It  is  this  analysis  of  the 
mortality  from  consumption  by  age-periods  which  shows  with 
startling  clearness  the  economic  significance  of  the  disease.  It 
attacks  preferably  either  young  men  and  women  who  are  just 
beginning  to  repay  to  society  the  capital  that  has  been  in- 
vested in  them  through  the  years  of  their  helplessness  and 
education,  or  those  who,  a  little  farther  on  in  life,  are  at  the 
height  of  their  productive  capacity  and  have  families  dependent 
on  them. 


41 


'PROPORTION  OP  MORTALITY  CAUSED  SyCONSUMPTlOS 
IN  NEW  YOBK  CITY.  1901. 


20  -  29  years . 


MEN 


30  -  44  yeara. 


20  -  29  years , 


WOMEN 


30  -  44  years ^ 


Diagram  III 


42 


MARITAL  CONDITION 

An  analysis  of  the  mortality  from  consumption  according  to 
marital  condition  is  chiefly  of  value  for  pointing  a  statistical 
moral. 

There  is  a  table  in  Section  IX.,  of  Part  I.,  of  the  Report  on 
Vital  Statistics  of  the  Census  of  1900,  which  shows  the  death- 
rate  of  the  single,  the  married,  and  the  widowed,  from  certain 
important  diseases  and  classes  of  diseases.  This  table  seems 
to  support  Robert  Louis  Stevenson,  with  evidence  he  did  not 
adduce,  in  his  assertion  that  "marriage  is  a  field  of  battle  and 
not  a  bed  of  roses  " — a  battlefield,  moreover,  where  the  fatali- 
ties are  many ;  for  the  death-rates  from  nearly  all  of  the  dis- 
eases, consumption  included,  are  considerably  higher  among 
the  married  than  among  the  single,  and  still  higher  among  the 
widowed. 

As  marriage,  however,  and  widowhood  are  phenomena  of 
only  certain  ages,  and  of  those  ages  at  which  consumption  is 
especially  destructive,  while  the  single  class  includes  a  large 
proportion  of  children,  who  are  comparatively  free  from  this 
disease,  the  table  is  palpably  misleading  unless  the  element  of 
age  is  taken  into  account. 

Table  5  and  Diagram  IV.  show  the  death-rates  from  con- 
sumption of  the  single,  the  married,  and  the  widowed  over 
fifteen  years  of  age,  in  each  of  three  age-groups. 


Table  5. — Death-Rates  by  Marital  Condition  and  Age  per  100,000  Popu- 
lation OF  Corresponding  Ages 


• 

Age 

Marital 
Condition 

15  to  44  years 

45  to  64  years 

65  years 

and  over 

Males 

Females 

Males 

Females 

Males 

Females 

Single 

292.2 
208.3 
667.0 

223.4 
237-6 

356.7 

565-3 
223.1 

487.4 

235-6 

153-7 
189.3 

604.1 
244.2 
312.0 

296.0 

Married 

236.1 

Widowed 

213.2 

43 


In  general,  the  rate  was  lower  for  the  married  than  for 
either  the  single  or  the  widowed,  and  lower  for  women  than 
for  men.  The  only  place  where  it  was  higher  for  women  than 
for  men  was  among  the  married  in  the  age-group  fifteen  to 
forty-four  years,  and  here  it  was  also  higher  than  for  the  single 
women  at  the  same  ages.  This  variation  may  be  explained  by 
reference  to  statements  of  such  physicians  as  Dr.  Flick  of 
Philadelphia  and  Dr.  Osier  of  Baltimore  to  the  effect  that 
"pregnancy  is  found  to  complicate,  to  develop,  or  to  precip- 
itate phthisis  remarkably." 


MALES 


15-44  years 


FEMALES 


^ft'jr        ^ 


7o        So 
/I 


XQ%  ^% 


45-64  years 


65  years  and  over 


idi%        ^ 


z^^^^^sss^ 


/I 

3 

££ 

*UVs^'!s\^'s4 

^^^^^^ 

r 

*<) 


% 


l=single.       2=inarried. 
Diagram  IV 


3=widowed. 


The  highest  rate  of  all  is  found  among  widowers  under 
forty-four  years.  In  the  other  two  age-groups  the  rates  for 
both  widowers  and  widows,  while  higher  than  for  the  married, 
were  lower  than  for  the  single.  The  cases  of  infection  from  a 
consumptive  husband  or  wife,  known  to  be  of  common  oc- 
currence, are  more  apt  to  appear  here  than  among  the 
married. 

The  high  rates  found  among  the  single  are  due  largely  to 
occupation  and  to  the  fact  that  a  far  higher  percentage  of  the 
single  than  of  the  married  live  in  cities,  where  the  devastation 
is  much  greater  than  in  the  rural  districts. 

44 


To  show  more  clearly  the  importance  of  consumption  as  a 
cause  of  death,  the  percentage  of  mortality  due  to  this  disease 
is  shown  in  Table  6  and  Diagram  V. 


Table  6. — Number  of  Deaths  Caused  by  Consumption  per  ioo  Deaths  from 

ALL  Causes,  in  Certain  Groups  of  the  Population,  Classified 

According  to  Marital  Condition,  Sex,  and  Age 


Age 

Single 

Married 

Widowed 

Males 

Females 

Males 

Females 

Males 

Females 

All  over  15  years 

26.S1 

27.30 

12.88 

16.21 

7.51 

5.47 

15-19     " 
20-24     ' ' 

22.81 

33.93 
40.82 

26.71 
30.35 

23.02 
31.00 

25.00 
42.22 

33-o8 

29.79 

25-34     " 

35-13 

40.38 

29.87 

30.33 

43.32 

3S.55 

35-44     " 

28.65 

23.30 

22.43 

20.24 

30.57 

24.31 

45-54     " 

20.44 

13.61 

13.09 

10.95 

19.80 

10.37 

55-64     " 

11.92 

7.85 

8.25 

6.61 

8.89 

6.27 

'    65  years  and  over 

5.60 

3-34 

3.26 

3.61 

2.68 

2.40 

For  all  ages  over  fifteen,  it  is  seen  that  consumption  caused 
a  larger  proportion  of  the  deaths  among  married  women  than 
among  married  men,  though  the  actual  death-rate  was  lower. 
It  caused  the  greatest  proportion  among  the  single  of  both 
sexes,  and  the  smallest  among  the  widowed.  This  is  ex- 
plained largely  by  the  age  composition  of  the  two  classes,  the 
single  having  a  large  number  of  individuals  at  the  ages  when 
consumption  is  especially  prevalent,  while  the  average  age  of 
the  widowed  is  high. 

It  appears,  further,  that  at  most  ages  consumption  was  a 
less  important  cause  of  death  among  the  married  than  among 
the  single  or  the  widowed.  Among  the  married  men,  how- 
ever, it  was  more  important  than  among  either  the  single  or 
the  widowed  at  the  ages  of  fifteen  to  nineteen  years,  and 
slightly  more  important  than  among  the  widowed  at  twenty  to 
twenty-four  years.  At  both  of  these  periods  the  figures  for 
married  and  widowed  are,  of  course,  small  and  of  correspond- 
ingly less  significance. 

45 


Consumption  was  also  a  more  important  cause  among  mar- 
ried women  than  among  widows  at  the  ages  of  forty-five  and 
over. 

Among  single  men  it  was  responsible  for  a  large  proportion 


MALES 


SINSLE 


65  and  over 
55-64 
45-54 
35-44 
25-34 
20-24 
15-19 


65  and  over 
55-64 
45-54 
35-44 
125-34 
'20-24 
15-19 


65  and  over 
55-64 
45-54 
35-44 
25-34 
20-24 
15-19 


So 


W% 


TEUALES 


^°%         ^ 


MARRIED 


I ("   ' 


^^ 


^mzzL 


:m2 


ss^g 


^^^^^!^ 


^^ 


WIDOWED 


^% 


^% 


Diagram  V 


of  the  deaths  at  all  ages  from  twenty  to  fifty-five;  among 
single  women  its  greatest  ravages  appeared  between  fifteen  and 
thirty-five.  Among  the  married  of  both  sexes  and  among  the 
widowed  it  was  of  most  importance  at  the  ages  twenty  to 
thirty-five.  The  highest  percentage  of  all  is  found  among 
widowers  between  twenty-five  and  thirty-four  years  of  age, 
where  consumption  caused  forty-three  per  cent  of  the  591 
deaths  from  all  causes. 

The  favorable  mortality  among  the  married — :the  men  at  all 
ages  and  the  women  in  the  ages  after  forty-five — is  found  in 
all  countries  in  the  general  death-rates  as  well  as  in  the  rates 
for  consumption.      Mayo-Smith  considered  this  favorable  mor- 

46 


tality  to  be  due  "partly  to  the  fact  that  marriage  in  itself  is 
more  or  less  a  process  of  natural  selection,  and  partly  to  the 
greater  regularity  and  soberness  of  life  induced  by  marriage." 
This  explanation  applies  with  especial  force  to  the  case  of  con- 
sumption, where  much  depends  upon  the  habit  of  life  and 
exposure  to  risks  of  all  sorts.  It  has  been  suggested  that 
alcoholism,  in  particular,  to  which  the  single  and  widowed  have 
more  temptation  than  the  married,  is  probably  an  important 
factor  in  increasing  the  prevalence  of  consumption  among 
them. 

Aside  from  this  the  variations  according  to  marital  condi- 
tion are  largely  a  matter  of  age  and  occupation,  and  thus  due 
to  attendant  rather  than  to  consequent  features  of  the  social 
relations. 

RACE 

The  influence  of  race  in  a  strict  sense  on  any  social  phe- 
nomenon is  hopelessly  obscured  by  the  historical  accidents  of 
conquest  and  migration  whereby  "groups  with  most  unlike 
social  traditions,  characteristics,  and  possibilities  are  united 
indistinguishably  in  one  group,  while  the  elements  of  what 
should  be  one  group  .  .  .  are  scattered  about  among 
several  groups." 

When,  realizing  that  color  and  birthplace  are  the  only  items 
in  the  census  enumeration  which  can  give  any  clue  to  race,  we 
try  on  this  basis  to  see  some  glimmerings  of  the  truth,  other 
dififlculties  arise.  The  influence  of  race,  even  with  this  modi- 
fied and  wholly  illegitimate  definition  of  the  term,  is  obscured 
by  the  presence  of  other  factors.  In  connection  with  this 
question  of  the  prevalence  of  consumption  such  other  factors 
are  the  age  and  sex  constitution  of  the  different  national 
groups,  their  distribution  between  city  and  country,  the  varie- 
ties of  climate  to  which  they  are  exposed,  and  their  economic 
and  social  conditions.  One  ends  by  feeling  the  force  of  the 
dictum  that  while  "we  need  not  deny  that  blood  tells,  we 
should  not  be  prematurely  certain  that  we  can  hear  what  it 
tells,  or  that  we  can  distinguish  the  voice  of  the  particular 
blood  that  speaks." 

47 


Table  7. — Mortality  in  the  Registration  Area,  by  Color 


Population 

Mortality 

Color 

From  all  Causes 

From 
Consumption 

^   K   0 

0     rx,     T^ 

f-'  [2  2 

Number 

Rate  per 
1000 

Number 

Rate  per 

1000 

Percei 

Deati 

Co 

White 

27,555,800 
1,251,469 

475,640 
36,625 

17.29 
29.27 

47,641 
6,063 

1.74 

4.84 

10.05 

Colored ' 

16.55 

•  Includes  all  persons  of  African  descent,  Indians,  Chinese,  and  Japanese. 

The  most  obvious  comparison  in  the  United  States  is  based 
on  the  broad  distinction  of  color.  It  is  seen  from  Table  7  that 
while  the  general  mortality  of  the  colored-  is  seventy  per  cent 
higher  than  that  of  the  white  population  the  consumption 
death-rates  show  a  far  greater  difference,  the  rate  for  the  col- 
ored being;  not  far  from  three  times  the  rate  for  the  white. 
The  age  constitution  of  the  two  classes  explains  none  of  the 
difference,  since  the  percentage  of  population  at  the  ages  when 
consumption  works  most  of  its  destruction  is  almost  the  same. 
As  shown  in  Table  8,  forty-two  per  cent  of  the  white  popula- 
tion is  between  fifteen  and  forty  years  of  age,  and  42.  i  per  cent 
of  the  colored.     For  explanation  of  the  high  death-rate  from 

Table  8. — Percentage  of  Population  at  Certain  Age-Periods,  by  Color 


White 

Colored 

Age 

Total 

Negro 

Chinese 

Japanese 

Indian 

12. 1 
22.4 
42.0 

23  5 

13-7 
25.9 
42.1 

18.3 

13.9 
26.2 
46.2 
13-7 

1-3 
2.2 

44-5 
52.0 

0.7 

1.2 

91.4 

14.5 

5  to  14  years 

25.7 

37-2 

40  years  and  over 

6.7 

22.6 

48 


consumption  among  the  colored  population,  it  is  better  to 
consider  the  different  elements  of  this  group,  which  differ  one 
from  another  as  much  as  they  differ  from  the  whites.  For 
this  purpose  figures  for  the  registration  area  are  given  in  Table 
9,     The  death-rate  from  consumption  is  higher  for  all  elements 

Table   9. — Mortality   of  the  White   Population  and  of  the  Colored 
Races  in  the  Registration  Area,  1900 


White . . 
Negro . . 
Indian. . 
Chinese. 
Japanese 


Percentage 
OF  Popula- 
tion OF  THE 
U.  S.  Found 
IN  Registra- 
tion Area 


41,00 
13.00 
5.00 
54.00 
34.00 


Death-Rates  per  1,000 


All  Causes 


17-3 
30.2 
22.8 
18. 8 
10.3 


Consumption 


1-74 
4.85 
5-07 
6.57 
2.40 


Percentage 
OF  all 
Deaths 
Caused  by 
Consump- 
tion 


10.03 
16.07 
22.23 

34-94 
23.26 


of  the  colored  population  than  for  the  white  (i-74  per  1000), 
but  it  varies  from  2.4  per  looo  among  the  Japanese,  to  6.57 
per  1000  among  the  Chinese.  These  figures  are  unsatisfactory 
in  that  only  a  small  percentage  of  the  negro  and  Indian  popu- 
lations of  the  country  is  found  in  the  registration  area,  but  the 
statistics  for  the  whole  country  are  too  unreliable  to  be  used. 

The  difference  between  the  Japanese  and  the  white  popula- 
tion is  not  too  great  to  be  attributed  to  the  difference  in  age 
constitution  of  the  classes,  over  ninety-one  per  cent  of  the 
Japanese  being  between  the  ages  of  fifteen  and  forty.  The 
Chinese  also  have  an  insignificant  proportion  of  children,  and 
are  found,  moreover,  almost  entirely  in  cities,  and  in  the  worst 
parts  of  the  cities,  in  insanitary  surroundings.  As  a  natural 
consequence  of  their  object  in  coming  to  America — to  amass  a 
fortune  and  take  it  back  to  China — they  are  almost  invariably 
undernourished.  Their  constitutions  are  weakened  by  drugs, 
and,  except  on  the  Pacific  Coast,  they  are  under  the  additional 
disadvantage  of  unaccustomed  extremes  of  climate. 

49 


The  five  per  cent  of  the  Indians  of  the  United  States  living 
in  the  registration  area  illustrate  the  disastrous  effect  of  civil- 
ization on  a  savage  race.  Consumption  follows  on  the  transi- 
tion from  life  in  the  open  to  conditions  of  city  life,  and  its 
ravages  are  increased  by  the  craze  for  "fire-water,"  against 
which  the  savage  constitution  has  no  power  of  resistance. 

The  case  of  the  negroes  is  more  complex.  To  some  extent 
they  also  are  suffering  from  a  civilization  foreign  to  their 
nature,  imposed  upon  them  and  not  evolved  by  themselves. 
The  rivalry  between  the  supporters  of  environment  and  of  race 
characteristics  as  the  chief  explanation  of  the  present  inferi- 
ority of  the  negroes,  as  a  whole,  whether  physical,  mental,  or 
moral,  bids  fair  to  go  on  to  the  end  of  the  chapter,  since  the 
combatants  on  either  side  display  the  open  mind  of  the  Scotch- 
man who  declared  himself  willing  to  be  convinced  by  his  op- 
ponent in  argument,  but  added  suggestively  that  he  would  like 
to  see  the  man  who  could  convince  him.  Even  those  who  are 
inclined  to  think  all  the  disabilities  of  the  negroes  inherent  and 
ineradicable  admit,  however,  that  such  disabilities  are  probably 
aggravated  by  the  conditions  under  which  they  live. 

Certain  facts  about  their  social  and  economic  conditions 
have  a  direct  bearing  on  this  problem  of  consumption.  Every- 
where the  mass  of  the  people  is  ignorant  of  the  simplest  laws 
of  hygiene.  They  are  prone  to  have  an  aversion  to  water, 
a  preference  for  an  unwholesome  diet,  and  to  choose  their 
clothing,  when  they  have  a  chance  to  choose  it,  for  its  decora- 
tive rather  than  for  its  utilitarian  value.  Generations  of  de- 
pendence have  left  them  with  a  child-like  faith  in  the  interest 
and  activity  of  higher  powers  in  their  behalf,  which  from  the 
economic  standpoint  is  mere  unromantic  improvidence.  Until 
the  Civil  War  they  were  an  agricultural  people;  for  the  last 
forty  years  the  city  has  been  drawing  them  away  from  the 
fields.  In  all  cities  they  live,  for  the  most  part,  in  the  worst 
districts,  crowded  together  in  tenements  often  unfit  for  habita- 
tion. Their  work,  if  they  succeed  in  getting  any  and  keeping 
it,  is  indoors.  Their  whole  life  is  thus  spent  in  confinement, 
in  unfavorable  contrast  with  their  ante-urban  experience,  when 

50 


practically  all  of  the  daylight  hours  were  spent  in  the  open  air, 
and  when  their  cabins,  however  crowded  at  night,  and  dirty, 
and  dark,  were  rarely  sufficiently  well  built  to  provide  against 
ventilation.  In  the  cities,  therefore,  the  ignorance  and  care- 
lessness of  the  race  in  regard  to  laws  of  health  find  no  let  or 
hindrance  to  the  working  out  of  their  logical  consequences.  In 
the  larger  cities  of  the  North,  moreover,  the  severity  of  the 
winter,  sufficiently  trying  to  the  semi-tropical  constitution 
under  favorable  circumstances,  becomes  serious  in  its  conse- 
quences when  sufficient  clothing  is  not  only  unobtainable,  but 
its  importance  not  understood. 


Table  io. — Mortality  from  Consumption  in  Certain  Southern  Cities  and 
IN  the  Rural  Part  of  Certain  Southern  States,  igoo 


City  or  State 


I.  Cities: 

Mobile,  Ala 

Washington,  D.  C 

Atlanta,  Ga 

Savannah,  Ga 

New  Orleans,  La. 

Charleston,  S.  C  ....    

Memphis,  Tenn 

Nashville,  Tenn 

II.   States  (excluding  cities  given  above): 

Georgia 

Louisiana. 

South  Carolina 

Tennessee 

Florida 


51 


Popu- 
lation 


38,469 
278,7x8 

89,872 

54,244 
287,104 

55,807 
102,320 

80,865 


2,072,215 
1,094,521 
1,284,509 

1,837,431 
528,542 


Mortality  from 
Consumption 


Death-Rate 

per  100,000 

Living 


271.0 
210.4 
220.0 

245  I 
256.0 
189.8 
169.9 
222.5 


72.4 
54-5 
71.2 
166.4 
78.3 


U 


591-8 
513-8 
505.9 
529-5 
629.5 

674.7 
37S.4 
63S.5 


138.1 
122.9 
199.0 
368.9 
140. 1 


Excess  of 

Colored 

Death-Rate 


C    (U    w 


320.8 

303-4 
285.9 
284.4 
373-5 
484.9 
20S.5 
416.0 


65-7 

68.3 

127. 8 

202.5 

61.8 


O 


1x8. 4 
X44.2 
130.0 
1x6.0 
145.9 
255.3 

X22.7 
186.9 


90.7 
125.2 

179-5 

121. 7 

78.9 


Industrial  conditions  and  irresponsibility  on  the  part  of  hus- 
bands and  fathers  too  often  make  the  mother  the  chief  or  sole 
wage-earner,  and  the  children  are  thus  left  to  grow  up  as  they 
can.  The  small  proportion  who  succeed  in  living  through 
childhood  and  youth  arrive,  many  of  them,  at  maturity  with 
a  weakened  constitution  and  habits  of  life  which  offer  every 
encouragement  to  the  bacillus  tuberculosis.  In  the  registration 
area,  where  ninety-three  per  cent  of  the  negroes  are  found 
in  cities,  it  is  not  surprising  that  even  among  the  children 
consumption  is  prevalent.  The  death-rate  from  consumption 
under  fifteen  years  of  age,  which  is  only  31.8  per  100,000  for 
the  white  population,  is  246  for  the  colored,  a  rate  considerably 
higher  than  is  found  at  any  age  among  the  native-born  whites 
of  native  parentage. 

The  bearing  of  city  conditions  on  this  point  is  indicated  by 
the  figures  given  in  Table  10  (Diagram  VI.).  It  is  seen  that  not 
only  is  the  death-rate  for  the  colored  much  lower  in  the  rural 
parts  of  states  containing  a  large  negro  population  than  in  the 
cities  of  those  states,  but  in  almost  every  case  the  difference 
between  white  and  colored  is  considerably  less  in  the  country 
than  in  the  city. 


Tm 


DEATH    RATES  TROM  CONSUMTTIOH.ISOff, 


Xte<irfi9 


]lun|Sa     HasAvfUt  ntofhia  "BuraiTm 
M- (Marti. 


k 


i  25-4.  /JO.  -f^.      iM.  ^V3:  jyi.  ^a-  tsr.  7x.      ^n.  vi  i-i^-  7^ 
SewOrtiatn  Hura/td.  Sa^iumoh  Arfan^  RlirdJ  Gn    MobilCi/k.  ftesiiA- 
0  -wiiite 


NewVirliCt^  BMai> 


Diagram  VI 
52 


Turning  to  the  various  elements  of  the  white  population  it 
is  necessary  to  take  into  consideration  the  factor  of  age,  and 
since  about  seventy  per  cent  of  all  deaths  from  consumption 
occur  between  the  ages  of  fifteen  and  forty-four,  the  death- 
rates  at  these  ages  constitute  the  best  index  of  the  suscepti- 
bility of  the  difTerent  nationalities.  The  birthplace  of  mothers 
is  used  as  the  basis  of  classification  in  order  that  as  large  a 
quota  as  possible  of  the  national  group  may  be  included. 

In  Table   ii  (Diagram  VII.),  the  nationalities  are  arranged 


Table  ii. — Mortality   from  Consumption,   15   to  44  Years  of  Age,  by 
Color  and  Nationality 


Color  and  Nationality 


Total  Colored 

White. 

Mothers  born  in — 

Ireland 

Bohemia 

Scandinavia , 

France ....    

Germany 

Scotland , 

Canada , 

United  States   . . . . . 
England  and  Wales 

Italy 

Russia 

Hungary '. 

Poland 


Death  Rate 
PER  100,000 
Population 


5S7.4 


428.0 

235.2 

233-7 
220.6 
205.9 
201. 1 
199.7 
162.5 

151.4 
149.9 
131.1 
II3-4 
67.4 


according  to  the  death-rate  from  consumption,  at  the  age  when 
this  disease  is  most  prevalent.  The  rate  for  the  colored  is 
greater  than  that  for  any  element  of  the  white  population. 
Among  the  white  population  the  Irish  easily  lead  the  way, 
with  a  rate  nearly  twice  as  high  as  that  of  the  Bohemians,  next 
below.  The  predilection  of  the  Irish  for  the  crowded  parts  of 
cities,  the  Celtic  tendency  to  take  no  thought  for  the  morrow, 
their  frequent  intemperance,  and  the  generations  of  poverty 

53 


behind  them,  are  circumstances  that  go  far  to  explain   their 
leadership  in  this  respect. 

The  position  of  the  Bohemians  next  is  probably  due  largely 


^^ 


ST7      505"      ;?5/        ^Oi        /(>2>       /^o        //3 
^Sr      ^'SV       flOG       ilCTD        /s-/        /3/  67 

Diagram  VII 

to  their  congregation  in  cities,  in  insanitary  housing  conditions, 
and  to  the  equally  insanitary  conditions  of  the  occupations  in 
which  they  engage.  It  is  hard  to  find  an  explanation  for  the 
high  rate  among  the  Scandinavians,  so  many  of  whom  live  in 
the  country.  It  has  been  suggested  that  the  effect  of  the  new 
climatic  conditions  may  be  to  weaken  the  vitality  as  well  as  to 
produce  the  radically  different  physical  type  of  the  second  gen- 
eration. Their  prejudice  against  ventilation  is  doubtless  a  factor. 

54 


Habits  in  regard  to  drink  help  to  explain  the  variations  in 
this  table.  The  Italians,  Russians,  Hungarians,  and  Poles  are 
found  at  the  lower  end  of  the  scale,  although  they  live  almost 
exclusively  in  the  tenement  districts  of  the  large  cities,  under 
far  worse  conditions  than  the  Germans,  or  even  the  Irish,  and 
have  a  large  preponderance  of  young  men,  the  class  most  liable 
to  consumption.  But  these  nationalities  are  comparatively 
free  from  drunkenness. 

The  case  of  the  Italians  is  especially  remarkable  because,  in 
addition  to  their  unfavorable  surroundings,  they  are  exposed 
to  extremes  of  climate  to  which  they  have  never  been  accus- 
tomed, and  are,  according  to  American  standards,  habitually 
underfed.  To  counteract  these  poor  conditions,  they  have  a 
temperament  to  which  worry  and  anxiety  are  foreign,  and  the 
men  engage  in  outdoor  occupations.  Almost  half  of  the 
Italian  men  work  here  as  common  laborers  on  the  construction 
of  streets  and  railroads,  while  an  aversion  to  the  strenuous  life 
leads  many  into  the  gentle  and  salubrious  calling  of  peddling. 
It  may  be,  also,  that  the  carnivorous  American  underrates  the 
dietary  value  of  macaroni  and  cheese. 

After  bringing  all  these  considerations  to  bear  on  the 
statistics,  there  remains  to  be  reckoned  with  the  testimony  of 
practical  workers  that  tuberculosis  is  more  common  among  the 
Italians  than  is  indicated  by  the  death-rate  in  early  middle  life. 
The  fact  that  tuberculosis  of  the  glands  and  joints  is  unusually 
common  among  Italian  children  would  also  make  one  expect 
a  higher  consumption  death-rate  among  the  older  generation. 
A  partial  explanation  of  this  discrepancy  is  found  in  the  at- 
tachment of  the  Italians  for  their  native  land,  which  frequently 
operates  to  find  a  way  of  sending  the  invalid  home  to  die 
among  the  vines  and  olive  trees  of  his  native  village. 

The  Russians,  Hungarians,  and  Poles,  who  show  a  still  lower 
death-rate  from  consumption  than  the  Italians,  are  nearly  all 
Jews,  and  throughout  the  world  Jews  are  found  to  have  a  com- 
paratively low  death-rate  from  this  disease.  Though  there  are 
indications  that  the  Americanization  of  the  Hebrew  immigrants 
is  being  accompanied  by  an  increased  susceptibility  to  this 

55 


disease,  it  is  true  that  they  are  still  comparatively  immune.  It 
is  probable  that  the  death-rate  among  the  Jews  is  not  an  accu- 
rate index  to  the  prevalence  of  the  disease,  for  the  reason  that 
among  them  the  average  duration  of  tuberculosis  is  much 
longer  than  among  other  races.  "Quick  consumption"  is 
almost  unknown,  and  the  disease  often  runs  for  eight  or  ten 
years  before  it  proves  fatal.  The  death-rate  may  be  lowered 
also,  though  to  a  less  extent  than  among  the  Italians,  by  the 
return  of  some  of  their  sick  to  Europe.  Allowing  for  this,  and 
assuming  that  consumption  is  considerably  more  prevalent 
than  the  death-rate  indicates,  it  still  appears  that  the  Hebrew 
constitution  has  a  remarkable  resisting  power.  This  power  of 
resistance  exists  in  spite  of  narrow  chests  and  slight  stature,  in 
spite  of  extreme  poverty  and  still  greater  frugality,  in  spite 
of  mental  overexertion,  lack  of  exercise,  employment  in  the 
sweated  industries,  and  contact  with  the  probability  of  infec- 
tion in  second-hand  clothing.  Various  explanations  have  been 
advanced.  Employment  in  occupations  where  they  are  pro- 
tected from  the  weather  can  hardly  be  looked  upon  as  an  ad- 
vantage. The  infrequency  of  alcoholism,  however,  and,  indeed, 
their  temperance  in  all  directions,  the  mandates  of  their  re- 
ligion in  regard  {o  a  careful  inspection  of  meat  before  it  can  be 
pronounced  "Kosher,"  and  in  regard  to  bathing  and  house- 
cleaning  at  certain  intervals, — all  these  circumstances  help  to 
account  for  the  fact  that  there  is  one  evil  which  has  not  been 
meted  out  to  this  ill-used  people  to  its  fullest  extent. 

Generalization  on  this  point  of  the  relation  between  con- 
sumption and  race  is  a  delicate  task,  but  a  few  conclusions 
seem  warranted.  Much  of  the  variation  in  consumption 
death-rates  in  the  United  States  is  due  to  the  adventitious 
circumstances  of  age  constitution,  and  urban  or  rural  residence. 
Eliminating  the  first  of  these  factors  and  making  allowance  for 
the  second,  the  differences  which  remain  seem  to  be  the  re- 
sultant of  a  variety  of  social  and  economic  influences.  One  of 
the  most  conspicuous  of  these  influences  is  that  exerted  by  our 
high-grade  civilization  over  the  less  advanced  peoples  within 
our  bounds,  resulting,  so  far,  chiefly  in  that  increase  of  sorrow 

56 


which  comes  to  him  "  who  increaseth  wisdom,"  without  the 
attendant  compensations.  Other  active  influences  include 
occupation,  liousing,  and  temperament,  and  habits  governing 
forms  of  dissipation,  food,  clothing,  and  exercise. 

To  go  back  still  farther  and  inquire,  in  regard  to  each  of 
these  influences,  the  relative  responsibility  of  fundamental 
racial  characteristics,  whether  physical,  mental,  or  moral,  and 
of  the  environment  in  which  these  characteristics  are  operat- 
ing, would  be  to  enter  on  a  speculation  only  less  alluring  than 
futile. 

To  supplement  this  analysis  of  the  death-rates  in  the  United 
States  another  table  is  given,  in  figures  and  in  graphic  form, 
showing  the  relative  importance  of  consumption  among  the 
principal  national  groups  in  the  registration  area  in  1900  and  in 
Manhattan  and  Bronx  in  1902.  (Table  12,  Diagram  VIII.) 
The  two  sets  of  figures  are  not  strictly  comparable,  since  the 
deaths  of  negroes  in  the  registration  record  are  not  given 
separately  from  those  of  the  total  colored,  and  Austrians  and 
Swiss  are  included  with  "all  other  countries." 

The  diagram  is  of  a  complexity  that  can  be  excused  only  by 
the  desirability  of  comparing  at  the  same  time  the  men  with 
the  women,  and  New  York  City  with  the  United  States;  it  is 
justified  if  it  makes  the  differences  somewhat  more  evident  than 
the  table,  even  though  it  does  not  come  up  to  the  ideal  in  the 
way  of  simplicity. 

The  nationalities  are  arranged  according  to  the  importance 
of  consumption  among  the  men  in  New  York,  which  is  repre- 
sented by  a  descending  series  of  solid  blocks.  The  blocks  for 
the  New  York  women  are  the  heavily  shaded  ones  of  the  same 
width.  The  percentages  for  the  men  and  women  of  the  regis- 
tration area  are  expressed  in  the  wide  blocks,  shaded  and  plain 
respectively,  superimposed  on  those  for  New  York  City.  To 
bring  out  that  there  are  four  distinct  series  of  blocks,  lines  have 
been  drawn  connecting  the  blocks  which  form  a  series.  Finally, 
two  lines  have  been  drawn  across  the  whole  diagram,  showing 
the  average  for  men  and  for  women  of  all  nationalities  in  New 
York  City.     The  averages  for  the  registration  area  were  both 

57 


a 

o 

< 

b 

O 

rn 

Bj 

-f. 

'< 

a 

bi 

> 

< 

•& 

^ 

15 

1 

O 

M 

r-i 

z 

H 

Pi 

O 

M 

05 

a 

w 

H 

K 

Q 

H 

z 

Z 

< 

X 

8> 

o 
o 

M 

^r^ 

o 

Z 

HH 

z 

" 

rn" 

o 

* 

M 

■? 

H 

<; 

o 

ffi 

OS 

rn 

H 

pq 

< 

a 

n 

w 

Q 

z 

H 

O 

<; 

z 

z 

D 

<i 

U 

H 

u 

C/3 

H 

w 

l-> 

^ 

H 

u 

in 
z 

O 

<; 

<: 

i>! 

< 

z 

z 

o 

en 

P< 

H 

ri 

Ph 

o 

y 

u; 

O 

Z 

J 

O 

<l 

u 

z 

In 

o 

O 

H 

u 

<i 

u 

J^ 

z 

-»: 

z 

O 

Eh 

a; 

^^  ■" 

c 

« 

►^i 

^j 

1 

1 

o  o  nl  OJ  o  CIh 
"CO                  m 

Ooo-^       «        t^inO"*t^       Mt^NTj-               tn 

1 

. 

£ 

c 
1 .2 

'rt 

c'5 

Hfo      to      inmmoTi-      oioNu 

< 

s 

u 

a 

o  P- 

MHM            (nroooOMmM        1^1 

^ 
W 

Q 

"i 

tC 

0 

w 

o 

1 

H 

4) 

Ul 

e            -cs         M 

1 

2 

r. 

^^  <u 

«     (M    ID          (N          00  ^     -^^O    H           0^  «    O  (^          1           -^         1 

B 

3 

ro^^f^      OO        t^oCTC^O        mro-^o*              vo        i 

t:3 

<  i 

<>  0_       'I-      H  oo_^oo  « oo_^      lo  t^  invo        1      00       1 

o> 

S 

iz; 

o 

" 

H 

b 
O 

c"^S  ..2 

VOOO         N        ooirjinov»M        vOHlrl^ 

u  c  rt  <u  o  a 

1^  M   (N        >n      o;   (N   ^oo_  ^      vq   «   H   1- 

•«*• 

-^00*  «        6^      coONOvt^in       oJn  -^cc 

i 

z 

m 

1 .2 

e            -"i         M 

1 

o 

yj 

^ 

(NtnM        0       t^iDMHM       -^^sN-fi-       1       in       [ 

OS 

c'5 

t^^t^       vo         VOOwMCO          NNwC 

o 

rt 

o  o< 

wO^M          M               VOfOMCO         l^M-vhtN 

:s 

P 

OB 

3 

CO  «                                m'                 CO 

c> 

O 

0 

w 

Ul 

53                  ^^              to 

Pi 

^ 

„   1) 

vo    '^  CO         «          «    r^so  00  OO          t^  IN  *0  VC 

vo 

6 

coin^j-       -ti-       mc^moo       wnow 

^i 

mroo.       m       «(>;.Oro«_       iNOf;t- 

VO 

3 

OvcT                            iom"         rn         c^m'hTh 

00 

!z; 

o 

vo 

c""^  S  1.2 

0  ovo       vo        N  ro  r^  ID  M        coo  OO  OQ 
5roi>.      CO       00  OO  en  qvq        ininioc 

•<3 

OO  rt  u  o  S. 

t 

tfj 

6'*-<^        r^        h4-iAc>0>        i>.vo'   m    r 

« 

a 

"« 

o 

rS 

,   o 

coo       o        HM-o^io      vomOtN 

"rt 

=!'S 

ot>.       M        McowmiH        Hvo  fOoc 

B 

o  o. 

1 

0 

OE 

3 

« 

o 

X 

z 

1) 

0    w   Tt-       vo        vo   tH    N    rovo        00    0   O  (N 

Ov 

o 

B 

(^  m       in      ^o  -^00  vD  «        looo  m  r 

H 

tn 

^1 

ts.(N                       t^Nt-^            mwn 

P3 

3 

h' 

oo" 

■^ 

o 

Q 

< 

< 

H 
< 

1  "                   C 

^"rt  S  o  ,  2 

com       ''I-      oomirjoo.       tviniNO 

o  o  rt  0)  o  Ph 
(i   MQ^         3 

oooin       w        Tj-rj-(NOO        HOr-.c 

^                OO 

d   M   M       CO         4  <N   o*   6   o"        0\  C  rC.  H 

^ 

2 

< 

UI 

-c 

c 
1  2 

«    M   H        VD          0    t^vo  vo    «         Tf  TT  H    0 

•« 

rt 

■='5 

Nooo       <N        cniDroCio       mQioc 

rt 

o  ft 

OO                            r*-,            N             M 

^ 

S 

0 

OB 

3 

o 
u 

^ 

■^ 

^ 

V 

"^j-  m  o\     00        c^  M  o  ooo      CO  00  ■*  cs 

O 

B 

S  2 

■>                   OV 

O 

MM                        iH   H    rooo              en  H   -^ 

3 
I? 

« 

O 

c 

•?g  •  ■  : 

■»-» 

j'-g^  ^'SJ 

>< 

, 

'S 

>.  ?         Id"! 

_c 

1 
.S 

■a 

'^ 

i 

H 

<! 

c. 

c 

l-< 

o 
XI 

c 

h 
If 

c 

> 
c 

E 

I- 

!1   3   C   S'ii   3   Q   ct 

C 

_o 

iz; 

^Sog'oMfa     Ow<JtDO     rtW-i 

(_ 

§^ 

s 

< 

1 

2| 

felz; 


3J3 
hto 

lb 

rt  C 


58 


59 


so  close  to  the  average  for  women  in  New  York  that  they  were 
not  included  in  the  diagram;  not  only  would  their  own  signifi- 
cance have  been  obscured,  but  they  would  have  added  ma- 
terially to  the  confusion  already  presented  by  the  number  of 
elements. 

While  the  series  of  solid  black  blocks  descends  steadily  from 
the  fifty  per  cent  among  the  Chinese  to  the  twenty-two  per 
cent  among  the  Italians,  the  other  varieties  of  blocks  do  not, 
as  is  easily  seen  from  the  crossing  of  the  lines  which  connect 
them,  form  three  other  uniformly  descending  series,  at  equal 
distances  from  one  another  and  from  the  first  series.  On  the 
contrary  they  make  conspicuous  deviations. 

In  comparing  Manhattan  and  Bronx  with  the  registration 
area  it  is  noticeable  that  with  only  one  exception  the  percent- 
age for  men  is  higher  in  the  former,  while  the  percentage  for 
women  is  higher  in  the  registration  area  than  in  the  city  among 
six  of  the  thirteen  national  groups,  and  in  most  of  the  others 
the  difference  is  very  slight.  Inasmuch  as  about  one-fourth  of 
the  population  of  the  registration  area  is  rural  in  the  census 
definition  of  the  term,'  these  figures  seem  to  support  the  con- 
tention that  women  living  in  the  country  and  in  small  towns 
do  not  profit  equally  with  men  from  the  abundance  of  sun  and 
air  at  their  command.  They  are  apt  to  keep  to  the  house 
more  closely  than  do  the  women  of  the  city  and  too  often 
their  standard  in  regard  to  ventilation  is  as  low  as  that  of  the 
tenement  dweller.  The  comparison  by  nationalities  further 
suggests  that,  disregarding  the  Scotch  and  Canadians,  where 
the  figures  in  New  York  are  too  small  to  be  accepted  as  trust- 
worthy, among  the  Irish,  the  negroes,  the  Germans,  and  the 
Russians,  Roumanians  and  Poles,  the  burden  of  the  unfavor- 
able conditions  attending  life  in  New  York  City  falls  on  the 
men. 

The  particularly  valuable  feature  of  the  statistics  is  that  they 
bring  out  certain  contrasts  between  the  men  and  the  women 
of  the  different  groups.  The  greatest  contrasts  are  found 
among  the  Scotch  and  the  Russians  in  Nev/  York,  where  the 

'  "  Rural "  includes  places  of  less  than  8,000  inhabitants. 
60 


difference  in  favor  of  the  women  is  respectively  nine  and  six 
times  as  great  as  in  the  averages  for  the  total  population. 
Among  the  Scandinavians  and  the  Italians,  on  the  other  hand, 
both  in  New  York  and  in  the  registration  area,  and  among  the 
Canadians  of  the  registration  area,  the  advantage  is  with  the 
men,  in  bold  violation  of  the  general  rule. 

Explanations  can  only  be  hazarded.  It  would  seem  that 
the  Scotch  constitution,  re-enforced  by  a  simple  and  whole- 
some diet,  ought  to  be  naturally  inhospitable  to  the  bacillus 
tuberculosis,  and  that  if  it  were  not  for  the  element  of  intem- 
perance both  men  and  women  would  have  a  low  degree  of  sus- 
ceptibity  to  consumption.  For  this  reason  the  percentages 
for  the  United  States  seem  far  more  reasonable  than  those  for 
New  York  City,  and,  considering  the  small  numbers  on  which 
the  latter  are  based,  the  most  plausible  explanation  for  them 
is  that  they  are  not  indicative  of  the  real  conditions  in  the  city. 
The  great  difference  among  the  Russians,  Roumanians,  and 
Poles  in  New  York  may  be  due  to  the  Jewish  ideals  which  keep 
the  woman  in  the  home,  and  protect  her  as  far  as  possible  from 
the  struggle  for  existence,  as  well  as  to  the  almost  incredible 
efforts  which  the  husband  and  father  makes  in  the  struggle,  and 
the  character  of  his  usual  occupations.  Doubtless  this  struggle 
is  nowhere  else  so  hard  as  it  is  in  New  York,  and  since  the 
figures  in  this  case  are  comparatively  large  it  may  be  allowable 
to  assume  that  while  ordinarily  consumption  is  comparatively 
rare  among  both  men  and  women  of  these  nationalities  the 
conditions  of  life  in  New  York  City  tend  to  increase  it  con- 
siderably among  the  men. 

Among  the  Italians  the  same  general  social  principle  in  force 
among  the  Hebrew  peoples — that  the  woman's  place  is  at  home 
— has  exactly  the  opposite  effect  on  the  relative  susceptibility 
to  consumption.  But  this  is.  easily  understood  by  reference 
to  the  amount  of  home  work  done  by  the  Italian  women  to 
supplement  their  husbands'  earnings,  their  lower  average  of 
eflficiency  as  housekeepers,  which  tends  to  make  their  homes 
less  hygienic  than  those  of  the  Jewish  women,  and,  on  the 
other  hand,  the  prevailing  out-door  element  in  the  occupation 

61 


of  the  men.  As  this  element  is  more  prevalent  everywhere 
else  than  in  New  York  it  is  natural  that  its  influence  should 
be  especially  marked  in  a  very  low  percentage  for  men  in  the 
registration  area. 

The  Scandinavian  women  show  the  highest  percentage  of  all 
in  New  York,  six  points  higher  than  the  average  for  women, 
while  the  Scandinavian  men  stand  almost  three  points  lower 
than  the  average  for  men.  The  same  relation  exists  between 
the  percentages  for  the  men  and  the  women  in  the  registration 
area.  Occupation  probably  has  much  to  do  with  this,  for  the 
women  go  into  domestic  service,  which,  as  will  be  seen  later, 
has  the  highest  general  death-rate  and  the  highest  consumption 
mortality  of  all  occupations  for  women,  while  the  men  are  apt 
to  be  carpenters,  seamen,  dock  builders,  or  day  laborers. 

Among  the  Canadians  also,  in  the  registration  area,  the  wo- 
men have  a  percentage  much  higher  than  the  men.  Both  are 
conspicuously  high.  Domestic  service  must  be  responsible  for 
the  abnormal  amount  of  consumption  (almost  forty  per  cent) 
among  these  women,  as  it  is  among  the  Scandinavians.  The 
figures  for  New  York,  as  in  the  case  of  the  Scotch,  are  too 
small  to  give  value  to  the  percentages. 

The  one  perfectly  safe  deduction  from  these  figures,  that  the 
importance  of  consumption  as  a  cause  of  mortality  among  the 
men  of  a  national  group  cannot  be  taken  as  an  index  to  its  im- 
portance among  the  women,  confirms  the  position  tacitly  as- 
sumed in  explaining  the  variations  in  Table  ii,  namely,  that 
"race  characteristics,"  strictly  speaking,  play  an  unimportant 
part  in  this  connection.  For  a  predisposition  to  consumption, 
or  an  inability  to  struggle  against  it,  would,  if  arising  from  the 
physical  type  of  the  race,  show  itself  equally  in  the  two  sexes. 
The  conclusion  is  plain  that  this  tempting  explanation  should 
be  used  only  as  a  last  resort. 

OCCUPATION 

To  disentangle  the  influence  of  occupation  on  the  death-rate 
from  consumption  is  an  undertaking  as  difificult  as  important. 

63 


If  the  difficulties  attaching  to  nomenclature  and  classification 
could  be  surmounted,  and  if  complete  statistics  by  age  periods 
were  available,  there  would  still  remain  influences  not  suscep- 
tible of  statistical  measurement  which  would  have  to  be  elimi- 
nated before  the  industrial  influence  could  be  estimated  justly. 
Such  factors  are  inherited  tendencies,  natural,  physical,  and 
mental  constitution,  conditions  of  life  outside  of  working  hours, 
and,  what  is  perhaps  most  potent  and  least  tangible,  the  pro- 
cess of  natural  selection  which  determines  the  personnel  in 
every  occupation. 

For  the  health  of  the  persons  found  in  any  employment  may 
be  the  explanation  of  their  presence  there  rather  than  the  re- 
sult of  it.  A  man  of  frail  physique  is  not  apt  to  become  a 
stone  cutter  or  an  iron  moulder,  nor,  on  the  other  hand,  does 
it  often  chance  that  a  strong  man  prefers  to  work  in  a  sweat 
shop  or  act  as  "ticket-chopper."  In  the  industrial  scale  there 
are  the  complementary  phenomena  of  the  "fit"  surviving  and 
pushing  on  to  higher  grades,  and  the  "unfit  "  dropping  down 
from  one  level  to  another.  At  the  bottom  are  found  the  inter- 
mittent and  casual  laborer  and  the  chronically  unemployed, 
— there,  for  the  most  part,  because  they  have  proved  unequal, 
in  some  point,  for  other  things.  By  this  automatic  sifting 
process  the  death-rate  is  kept  low  in  some  industries,  while  it 
is  correspondingly  raised  in  those  which  are  not  prohibitory  to 
persons  who  are  weak  or  ill. 

There  are  no  strictly  satisfactory  figures  on  this  point  of  the 
relation  between  occupation  and  consumption.  To  be  strictly 
satisfactory  they  should  be  large  enough  to  be  representative, 
they  should  be  given  separately  for  each  occupation,  and  they 
should  be  classified  by  age  and  nationality  as  well  as  by  sex. 

The  first  tables  and  diagram  apply  to  the  "registration 
states"  of  1900.  These  were  the  six  New  England  states, 
New  York,  New  Jersey,  and  Michigan,  with  the  addition  of 
the  District  of  Columbia.  Unfortunately  the  returns  from 
the  registration  cities  outside  the  registration  states  were  not 
received  in  time  to  be  incorporated  in  this  section  of  the 
census  analysis.     The  statistics  available,  therefore,  have  the 

63 


disadvantage  of  representing  only  a  small  area  of  the  United 
States,  and  that  an  area  comparatively  homogeneous  in  cli- 
matic condition  and  industrial  character.  They  have  in  com- 
pensation the  advantage  of  being  comparatively  reliable. 

For  the  purpose,  however,  of  showing  the  relation  between 
occupation  and  any  specified  disease  they  are  practically  value- 
less, because  of  the  omission  of  data  for  computing  death-rates 
from  different  causes  at  different  ages.  It  is  impossible  to 
draw  any  conclusions  about  the  influence  of  occupation  on  the 
prevalence  of  consumption  from  crude  death-rates,  since  con- 
sumption is  largely  a  phenomenon  of  early  and  middle  adult 
life,  and  the  proportion  of  men  at  those  ages  varies  from  less 
than  half  in  one  occupation  to  nine-tenths  in  another.  The^ 
statistics  here  given  accordingly  call  for  explanation  from  facts 
already  known,  and  an  opportunity  has  been  lost  of  making  a 
valuable  addition  to  the  subject  of  industrial  hygiene. 

The  first  table  (13)  gives  various  facts  about  men  engaged  in 
gainful  pursuits,  in  eight  classes  of  occupations.  While  most 
of  these  classes  contain  such  diverse  elements  that  the  facts 
about  the  combination  are  of  slight  significance,  it  is  still  worth 
noticing  that  the  high  death-rates  from  consumption  are  in 
those  occupation  groups  where  there  is  a  lower  average  of 
general  comfort  as  well  as  a  larger  proportion  of  persons  at  the 
age  most  susceptible  to  the  disease. 

In  the  diagram  (IX.)  these  eight  groups  are  resolved  into 
fifty-three  specific  employments  or  small  groups  of  employ- 
ments more  or  less  alike.  The  grouping  of  restaurant  keepers 
with  saloon  keepers,  etc.,  of  hotel  keepers  with  boarding-house 
keepers,  of  quarrymen  with  miners,  and  of  fishermen  and 
oystermen  with  sailors  and  pilots,  are  perhaps  the  most  regret- 
table combinations. 

It  is  noticeable  that  the  component  parts  of  the  eight  groups 
given  in  the  first  table  are  widely  scattered ;  for  example,  the 
first  four  employments  in  this  list,  the  twentieth,  the  thirtieth, 
and  the  forty-sixth,  all  belong  to  the  group  of  "manufacturing 
and  mechanical  industry  "  which  ranks  four  in  the  table  by 
groups. 

64 


Table   13. — Population,    Deaths,    and   Death-Rates,    of   Males   in    the 
Registration  States,  1900,  by  Classes  of  Occupations 


Occupations 


All  Occupations. 


Laboring  and  servant 

Clerical  and  official 

Public  entertainment 

Manufacturing  and  mechanical  industry. 

Personal  service,  police  and  military 

Professional 

Mercantile  and  trading. 


8.  Agriculture,  transportation,  and  other  outdoor 


AU  other  occupations. 


Population 


800,983 
424,781 
87,888 
1,796,928 
149,164 
203,104 

493-994 
1,528,241 


90,662 


s^  a, 

=  ><; 


Death- 

Rate 

from  all 

Causes 

(per 
1,000) 


20.2 
13-5 
15-4 
13-8 
12.9 
15-3 
12. 1 
IS.8 


6.5 


Mortality  from 
Consumption 


13,197 


3,018 
1,202 

236 
4,710 

380 

370 

819 

2,250 


2    0c 


The  consumption  death-rate  of  marble  and  stone  cutters  is 
six  times  that  of  bankers,  brokers,  and  officials  of  companies, 
and  the  mortality  in  the  other  fifty-one  employments  ranges 
between  these  extremes. 

It  must  be  remembered  that  in  the  case  of  consumption  there 
is,  more  often  than  in  most  diseases,  a  long  period  of  industrial 
decline,  during  which  the  man  drops  from  the  employment 
that  had  been  his  for  years  to  one  of  lower  grade,  or  through 
several  descending  grades,  to  the  ranks  of  the  unemployed.  The 
responsibility  of  his  death  is  in  this  way  fixed  not  on  the  occu- 
pation in  which  he  was  engaged  when  he  contracted  his  illness, 
but  on  the  last  one  in  Avhich  he  was  engaged  prior  to  his  death. 

The  high  death-rate  among  marble  and  stone  cutters  is  prob- 
ably due  to  the  irritation  of  the  respiratory  tract  by  fine  par- 
ticles of  marble  and  stone.  In  the  case  of  cigarmakers  and 
tobacco  workers,  who  rank  next,  it  is  probably  bad  air  and 
other  unsanitary  conditions  in  the  workroom,  combined  with 
equally  poor  conditions  at  home,  which  are  responsible,  rather 
than  any  inherent  feature  of  the  work. 

Plasterers  and  whitewashers,  hat  and  cap  makers,  tinners  and 

65 


,*  3 

ft    3 

^1^ 


e-5  - 


^K^KK  Life 
■■■   Boar 

I^HH  JaTtltOTZ 

^■H  Huckst 

■D  Iron   -y- 
^H  Carpenter 

■  Eng-«" 

■  Uarher 

■  ToifoTsprj 
I  Blacksmitfis 

Mate  I  1r  Iroara 


^H  TiTin 
■■  Clllr( 

■  Music 

■  Gla^s 
I  Barirers 

Sa.1  /ors , 


I  J'a.inTi.rs 
Leafhi 

m 


Boo /c  .(teeners,  c 

[rorers  (no?-  agT 

ers  y-linWare. 

net  makers    t- 

Y  teacher- 

ir  hairdressers 
pilot's,  fish  AT 
g/a.aiers.  V /a 

TnaAers  (12^ 

■pharmo.cistl 


Coo 


3ns  fi-ricfc  Tr 


Burch«rs(3ri 
S  aJoon  keepers.  /I'q 


rnen,  hacfcmei 

7767)  Vcana/menj^W) 

t  5e  xtons  (T^ 

?rs  "V-  pedd/ers 

■V-Conyeo(;oner 

sr«(  >/OTkfrs(l^ 

rsfir; 

>V0T-/cersfE7 


or; 

/ng.  house  /fet^i 
Mill  t-jacToTu    operaTi/es  (f^x> 


MQchin/5^s(:ir; 

Arch  ('reefs,  arti 
ftaTdeners.  y/o- 
sieians  V  suTgt 
cho-Titi  V  dea/eT 

(    SchoofcC^) 

(yr) 

v/atihmen , 

shoe  maMeTeQZ) 

sailors  ."V  man 

aucTione^TS,*t 

Iroad.   emplot^i 

m 

quarrymenfE2!) 
antcTS,  farm  ta 
rs,  cfjfcal.     Of 


%Ts,  teacher; 
/s/s,  rturser 

(w) 


agentsCr/ 


compaTiies  (j^ 


stone 
rers  **  JvhiTfe  »/a  shert 


■i  Ser/anrs 

I  Waf  T  ira/J 


■  Mart/e  r 

gar  TTiaAeri  V  To 
■p/ftsft. 
Composit  ors.  pr/nTeri-,-  V 

/erAs.'Vcopy, 
//•am/)  (I) 

i/ters-pr; 

upho/sTerers 
<^  music  fH) 
Workers  (TI) 

n.V  oysT&rmcn 
usher.  (IT) 


■>■  sTeamfitteiz^, 


LOr  d.ea/«r3.  [rar^enier. 


fecomonVel(l?5 


Km) 


arf  fsr; 

r-  Vtre^rowSr 


(?0 


eTn.rST) 


(m) 


CUlttrs  (W.) 
M'orAers  (IT) 

men(lZ) 


66 


tinware  makers,  cabinet  makers  and  upholsterers,  ranking  3,  6, 
9,  and  10,  respectively,  are  all  constantly  breathing  dust  of 
various  kinds.  Compositors,  printers,  and  pressmen,  fourth 
in  the  list,  work  in  notoriously  unhealthful  surroundings,  in 
crowded  rooms  with  little  ventilation,  often  so  dark  that  arti- 
ficial light  is  required,  even  in  the  daytime.  Servants  (5)  are 
generally  well-fed,  but  often  have  long  and  irregular  hours  of 
work,  poor  sleeping  arrangements,  and  too  little  fresh  air. 
Bookkeepers,  clerks,  and  copyists  (7)  breathe  impure  air  almost 
exclusively — in  the  office,  on  the  street-cars,  and  in  their  rooms 
and  places  of  recreation  in  the  evening. 

The  last  three  classes,  moreover,  show  a  large  proportion  of 
men  at  the  ages  when  consumption  is  most  prevalent. 

Under  the  heading  "musicians  "  is  included  a  wide  range  of 
social  conditions,  from  the  composer,  the  orchestra  conductor, 
the  opera  singer  and  the  concert  artist,  to  the  poorest  organ 
grinder.  A  large  proportion  pursue  their  vocation  in  the  close, 
overheated,  infected  air  of  the  cheaper  theatres,  dance  halls, 
and  restaurants,  or  earn  a  scanty  living  on  the  street,  where 
the  advantage  of  fresh  air  is  counterbalanced  by  exposure  to 
hunger  and  want  of  all  sorts.  The  irregularities  and  hardships 
of  the  life,  often  leading  to  intemperance,  would  be  enough  to 
establish  a  predisposition  to  consumption,  and  explain  the  high 
mortality,  were  there  not  also  the  consideration  that  no  small 
percentage  of  this  class,  especially  among  the  street  musicians, 
is  composed  of  the  broken-down  results  of  other  occupations. 

The  group  consisting  of  draymen,  hackmen,  and  teamsters, 
ranking  24,  and  the  janitors  and  sextons,  the  hucksters  and 
peddlers,  a  little  farther  on,  are  other  examples  of  occupations 
which  offer  a  refuge  to  men  who  are  either  not  naturally  strong, 
or  have  become  incapacitated  for  harder  work.  This  fact,  to- 
gether with  the  long  and  irregular  hours,  and  the  unresisted 
temptations  to  drink,  would  bring  about  a  higher  death-rate 
from  all  causes,  as  well  as  from  consumption,  were  it  not  for 
the  factor  of  plentiful  fresh  air  in  their  lives. 

Beyond  a  doubt,  saloon  keepers  and  bartenders  would  show 
far  less  favorable  mortality  figures  if  they  could  be  separated 

67 


from  the  restaurant  keepers,  with  whom  they  are  grouped ;  for 
not  only  are  they  apt  to  be  intemperate,  but  the  saloons,  in 
which  they  spend  much  of  their  time,  are,  for  the  most  part, 
infested  with  tubercle  bacilli. 

Hat  and  cap  makers  show  the  high  death-rate  which  would 
be  expected  from  the  conditions  under  which  they  work, — the 
overcrowded,  ill-ventilated  apartments,  their  constrained  po- 
sition, and  long  hours, — and  from  the  low  rate  of  wages,  entail- 
ing a  comfortless  home.  The  position  of  tailors,  however, 
below  the  average  death-rate,  and  number  33  in  the  list,  is  sur- 
prising. The  presence  of  large  numbers  of  Hebrews  would 
tend  to  lower  the  rates  in  both  branches  of  industry.  It  may 
be  that  the  dust  and  dyes  used  in  hat  and  cap  making  are  more 
injurious  than  in  the  garment-making  trades,  and  it  is  probable 
that  more  improvement  has  been  made  in  the  workrooms  of 
tailors  than  in  those  of  hat  and  cap  makers.  Glass  blowers,  in 
class  12,  show  the  influence  of  exposure  to  extreme  heat. 

The  class  of  non-agricultural  laborers  is  so  large  and  made 
up  of  so  many  elements  that  it  is  dangerous  to  generalize  about 
it.  It  is  safe  to  say,  however,  that  its  members  work  irregu- 
larly, at  an  exhausting  kind  of  labor,  which  induces  intem- 
perance, that  many  of  them  bring  from  Europe  constitutions 
weakened  by  a  struggle  with  hard  times  there,  and  live  here  in 
the  cheapest  of  lodging-houses  or  the  worst  of  tenements. 

All  these  occupations  with  a  noticeably  high  mortality  from 
consumption  belong  primarily  to  cities  and  large  manufacturing 
towns,  while  among  those  with  a  consumption  death-rate  be- 
low the  average  of  2.4  per  1000  are  found  almost  all  that  are 
carried  on  in  small  towns  or  in  the  country.  In  company  with 
the  outdoor  pursuits  are  all  of  the  professions,  the  better-paid 
trades,  and  other  occupations  which  imply  a  comparatively 
high  degree  of  comfort. 

The  position  of  miners  and  quarrymen  so  near  the  bottom 
of  the  list  requires  explanation,  since  the  exhausting  character 
of  their  work  and  the  amount  of  dust  they  inhale  would  sug- 
gest a  high  degree  of  susceptibility  to  this  disease.  English 
statistics  show  that  quarriers  have  a  high  consumption  mor- 

68 


Table  14.- 


-PopuLATioN,    Deaths,  and  Death-Rates,  of  Females   in  the 
Registration  States,  1900,  by  Occupations 


Population 

Death- 

Rate 

from  all 

Causes 

(per 

1,000) 

Mortality  from 
Consumption 

Occupations 

"3 
0 

Percentage 

15-44  Vears 

of  Age 

«s3 

1,587,874 

83.6 

8.3 

2,744 

1-7 

403,801 

7,801 

72,713 

16,566 

162,392 

29,122 

12,838 

195,176 

91,964 

41,912 

59,300 

33,780 

12,624 

19,755 

86.5 
97-3 
93.6 
88.8 
89-7 
89.1 
89.2 
83.2 
90.9 
68.4 
66.8 
98.3 
92.4 
43.8 

17. 1 

tt 
5.0 
4.0 

5-9 
4.1 

5-2 

5-9 
9-5 
5-1 
2.7 

1-3 
4-5 

I,2QI 
16 

144 
28 

234 
40 
17 

254 

116 
42 
56 
31 

6 
3 

3-2 

2.1 

*  2.  Telegraph  and  telephone  operators 

17 
1-4 
I  4 
1-3 
I  3 
1-3 

5.  Mill  and  factory  operatives  (textiles) 

8.  Dressmakers  and  seamstresses 

•9 
■9 
•5 

12.  Stenographers  and  typewriters 

^  13.  Artificial  flower  and  paper-box  makers 

All  other  occupations 

428,130 

78.4 

5-7 

466 

r.i 

'  Number  of  deaths  too  small  to  be  significant. 

tality  and  that  among  miners  the  rates  vary  enormously,  both 
with  the  kind  of  material  mined  and  with  the  locality.  The 
rates  for  tin,  copper,  and  lead  miners  are  very  high,  while  coal 
miners  show  varying  rates  in  different  coal  fields,  but  all  low. 
This  slight  susceptibility  of  coal  miners  is  attributable  largely 
to  the  fact  that  they  are  a  picked  class  of  men,  the  work  pre- 
cluding the  entrance  of  any  who  are  not  of  a  physique  above 
the  average. 

It  is  significant  of  the  improved  conditions  in  textile  factories 
that  the  150,000  operatives  have  a  death-rate  from  consumption 
of  only  2.1  per  1000. 

Most  of  the  rates  given  in  Table  14  indicate  that  the  deaths 
of  women  engaged  in  gainful  occupations  are  understated. 
This  is  even  more  apt  to  occur  among  women  than  among  men, 
for  the  reason  that  when  a  girl  or  woman  begins  to  lose  health 
she  can  stop  work  more  easily  than  a  man,  and  that  after  doing 
so  she  more  quickly  ceases  to  identify  herself  with  her  occupa- 

69 


tion.  The  natural  exit  from  her  occupation  being  by  marriage, 
not  death,  the  proportion  of  women  below  forty-five  years  of 
age  is  considerably  greater  than  the  proportion  of  occupied 
men,  in  all  occupations,  except  the  two  or  three  which  are  the 
resort  of  widows  and  of  single  women  unexpectedly  thrown  on 
their  own  resources.  With  this  large  proportion  at  the  ages 
when  consumption  is  most  prevalent  it  is  improbable  that  the 
death-rates  among  occupied  women  are  lower  than  they  are 
among  all  women.  The  rate  for  servants  is  the  only  one  which 
seems  reasonable. 

More  valuable  than  the  census  figures,  because  the  element 
of  age  is  taken  into  account,  are  those  which  were  presented 
by  Mr.  Frederick  L.  Hoffman,  statistician  of  the  Prudential 
Insurance  Company,  before  the  British  Congress  on  Tubercu- 
losis in  1900.  Mr.  Hoffman,  from  a  tabulation  of  the  experi- 
ence of  his  company  for  three  years,  found  that  consumption 
caused  the  highest  percentage  of  deaths  among  stone-workers, 
printers,  glass-workers,  brass-workers,  bookkeepers,  plumbers, 
salesmen,  hatters,  silk-workers,  and  cigarmakers.  In  all  of 
these  occupations  over  thirty-three  per  cent  of  all  deaths  were 
due  to  consumption.  Between  the  ages  of  twenty-five  and 
thirty-five  the  proportion  was  over  half  among  stone-workers 
(64.5  per  cent),  glass-workers  (58.7),  hatters,  bookkeepers,  and 
printers. 

Two  objections  might  be  urged  against  drawing  conclusions 
from  these  figures :  they  represent  a  selected  class  of  the  popu- 
lation, and  the  numbers  are  comparatively  small.  They  do, 
however,  correspond  with  what  would  be  expected  from  the 
characteristics  of  the  occupations  and  the  nature  of  consump- 
tion, and  are  therefore  of  value  in  the  way  of  confirmation. 

In  the  hope  of  throwing  light  on  local  conditions  a  tabula- 
tion by  occupation,  sex,  age,  and  nationality  has  been  made 
of  the  deaths  in  Manhattan  and  Bronx  in  1902.  The  only 
comparison  possible  is  of  the  deaths  from  consumption  with  all 
deaths  in  each  occupation.  The  figures  are  too  small  to  be 
regarded  as  representative.  It  is  hard  to  decide  just  how  small 
figures  may  be  and  still  give  a  percentage  which  will  justify 

70 


confidence.  For  this  probably  one  hundred  would  be  a  suffi- 
ciently low  minimum;  but  because  that  would  cut  out  of  con- 
sideration many  important  industries,  the  results  are  given  for 
all  occupations  showing  at  least  fifty  deaths  from  all  causes, 
with  the  warning  that  confidence  placed  in  the  percentages 
should  be  proportioned  to  the  size  of  the  figures  on  which 
they  are  based.  Their  chief  value  will  be  to  arouse  speculation 
and  to  start  investigations.  It  may  be  only  accident  that  of 
the  sixty-five  jewellers  who  died  in  New  York  in  1902  over 
thirty-eight  per  cent  died  of  consumption ;  but  even  if  the  real 
proportion  is  somewhat  lower,  it  is  probably  above  the  average 
for  all  men,  and  a  search  for  the  reasons  of  the  condition  indi- 
cated by  the  figures  should  have  good  results. 

In  the  table  (15)  the  total  number  of  deaths  from  all  causes 
and  from  consumption  is  given  for  men  of  fifteen  years  of  age 
and  over;  percentages  are  given  for  two  age-periods, — fifteen 
to  forty-four  years,  and  forty-five  to  sixty-four  years ;  the  oc- 
cupations are  arranged  with  reference  to  the  importance  of 
consumption  at  the  age  when  it  is  the  most  serious  problem. 
A  comparison  with  the  average  for  all  men  in  the  city  at  the 
same  age  is  given  in  an  additional  column,  in  which  each  per- 
centage is  represented  by  a  number  showing  its  relation  to  the 
average  percentage  considered  as  100.  A  200  in  this  column 
would  mean  that  in  that  particular  occupation  consumption 
caused  twice  as  many  deaths  as  the  average  proportion  would 
call  for,  while  a  50  would  indicate  only  half  as  many. 

It  is  proposed  to  make  these  figures  a  basis  for  investigation 
into  the  conditions  in  occupations  that  seem  particularly  in 
need  of  attention.  Until  that  has  been  done  it  is  useless  to 
attempt  to  account  in  detail  for  the  variations  exhibited  in  this 
table.  In  some  industries  with  an  undue  amount  of  consump- 
tion it  will  doubtless  be  found  that  the  conditions  under  which 
the  work  is  done  are  responsible  for  the  excess ;  in  others  the 
average  conditions  may  be  good  but  some  of  the  processes  may 
unavoidably  exhaust  the  vitality  of  the  workman  ;  in  still  others 
the  fault  may  lie  with  neither  work  nor  environment,  but  with 
the  low  standard  of  living  of  the  men  who  engage  in  it. 

71 


^ 


Table  15. — PRoroRTioN  of  Deaths  Caused   by  Consumption  among  Men 
Engaged  in  51  Occupations  in  Manhattan  and  Bronx,  1902 


Rank 
Accord- 
ing TO 
Per- 
centage 

OF 

Deaths 
Caused 
BY  Con- 
sump- 
tion 


Occupation 


Jeweller,  goldsmith,  silver- 
smith  

Cabinet-maker,  wood-carver 

Printer,  compositor,  type- 
setter  

Laundryman 

Shoemaker 

Machinist 

Stone-worker 

Bookkeeper 

Plumber,  gas  and  steam  fitter 

Musician 

Driver 

Clergyman,  rabbi 

Porter 

Barber 

Mason 

Waiter 

Laborer 

Watchman 

Clerk 

Peddler _ 

Painter,  glazier,  vamisher. . 

Cook. 

Hostler 

Plasterer,  decorator 

Butcher 

Salesman 

Saloon-keeper,  bartender 

Iron-worker 

Baker,  confectioner 

Tailor 

Longshoreman 

Cigarmaker 

Janitor 

Railroad  employee , 

Blacksmith , 

Motorman,  conductor 

Grocer , 

Carpenter 

Coachman 

Merchant , 

Fireman , 

Teacher,  author,  journalist. . 

Manufacturer , 

Engineer 

Agent,  collector 

Contractor,  builder , 

Policeman 

Sailor , 

Lawyer 

Physician,  surgeon 

Broker,  banker,  official.., 


All  Males,  New  York  City. 


15  Years 

Old  AND 

Over 


15-44  Years  of  Age      |  45-64  Years  of  Age 


Number  of 
Deaths 


52 
39 
60 

30 
79 

lOI 

31 

475 

10 

131 
58 
56 

151 

977 
34 

474 
68 

145 
65 
58 
38 
93 

133 

144 
37 
68 

246 
49 
88 
39 
39 
44 
55 
24 
99 
63 

III 

51 


105 
42 

13 
36 
36 
29 
21 
46 


18 
17 

44 
24 
18 
26 
13 
34 
43 
13 
194 
4 
52 
23 
22 

59 
337 

13 
181 

25 
53 


64.29 
56.67 

53-OI 
46.15 
46.15 

43-33 
43-33 
43-04 
42-57 
41-94 
40.84 
40.00 
39-69 
39.66 
39-29 
39.07 

38.59 
38.24 
38.19 
36.76 
36.55 
33-85 
32.76 
31.58 
30.11 
30.08 
29.86 

29-73 
29.41 
28.86 
28.57 
28.41 
28.21 
28.21 
27.27 
27.27 
25.00 
24.24 
23.81 
22.52 
IQ.61 
18.18 
18.18 
18.10 
16.67 
15.38 
13.89 
13-89 
^3-79 
4.76 

4-35 


32-84 


20 


196 

173 

161 
141 
141 
132 
132 

131 

130 

128 

124 

122 
121 
121 
120 

iig 

118 
116 
116 

112 
III 
1 10 
100 
96 
92 
92 
91 
91 


Number 

of 
Deaths 


26 


25.93 
25.00 

10.87 
54.84 
13. II 

18.33 
28.57 
10.87 
15.38 
26.67 
15.29 
0.00 
10.00 
13.64 
16.28 
16.67 
20.44 

8-33 

11.66 

15-79 

15.13 

i8.7S 

22.22 

12.50 

14.75 

20.88 

7.58 

23.53 

20.79 

10.99 

20.00 

13-85 

16.67 

27.77 

17.65 

12.50 

0.00 

20.00 

18.60 

8.22 

32.14 

8.57 

11.76 

8.45 

3-37 

8.33 

4.76 

5.00 

0.00 

0.00 

4-44 


2U 


73 


One  feature  of  the  table  is  worth  mention  even  if  its  full  sie- 
nificance  is  not  yet  clear,  and  that  is  the  striking  discrepancies 
between  the  ranks  of  many  of  the  industries  at  the  two  age- 
periods  given.  Of  the  twenty-two  occupations  which  stand 
above  the  average  in  regard  to  the  amount  of  mortality  due  to 
consumption  between  fifteen  and  fort)'^-five  years  of  age,  seven 
are  below  the  average  at  the  later  years ;  and,  conversely,  of 
the  twenty-eight  above  the  average  between  forty-five  and 
sixty-five,  thirteen  are  below  in  the  earlier  period  of  life.  In 
some  cases,  as,  for  example,  among  firemen,  it  seems  probable 
that  the  high  proportion  among  the  older  men  may  be  evidence 
of  the  effect  on  the  constitution  of  years  of  an  exacting  kind  of 
work,  while  the  same  characteristic,  by  demanding  a  certain 
high  standard  of  physical  strength  on  entrance  into  it,  keeps 
the  percentage  low  among  the  younger  men.  In  other  cases 
natural  selection  brings  about  the  opposite  result,  and  shows 
the  younger  men  susceptible  to  consumption,  while  the  older 
ones  are  comparatively  free  from  it.  The  occupation  of  watch- 
man, for  instance,  is  not  apt  to  attract  a  strong,  vigorous  man 
under  forty-five  years  of  age,  but  it  is  adapted  to  the  powers 
of  those  who  are  physically  below  par  and  is  often  sought  for 
men  in  the  incipient  stage  of  consumption,  x^nd  so  the  differ- 
ence in  personnel  in  this  occupation  above  and  below  the  age  of 
forty-five  is  probably  the  chief  explanation  for  the  contrast  in 
regard  to  tuberculosis,  rather  than  any  feature  of  the  work 
itself.  The  class  of  clergymen  barely  passed  the  requirement 
of  fifty  deaths  for  admission  to  the  list.  It  may  be  mere 
chance  that  among  them  consumption  caused  four  of  the  ten 
deaths  under  forty-five,  and  not  one  of  the  other  forty-one, 
but  these  figures  correspond  with  the  facts  as  observed  in 
England. 

Without  undertaking  further  explanations,  since  they  can 
be  at  best  only  suggestive  speculations,  the  characteristics  of 
an  employment  which  tend  to  make  consumption  unusually 
prevalent  in  its  ranks  may  be  summarized  as  follows  ; 

(i)  A  low  rate  of  wages,  entailing  discomfort  and  privations 
in  the  home. 

73 


(2)  Insanitary  conditions  of  place  of  employment. 

(3)  Exposure  to  dust  arising  from  marble,  stone,  plaster, 
wood,  metals,  or  textiles. 

(4)  Excessive  physical  exertion,  or  a  continued  constrained 
position. 

(5)  Close  confinement  within  doors. 

(6)  Exposure  to  excessive  heat. 

(7)  Temptations  to  intemperance. 

(8)  Long  or  irregular  hours. 

It  is  not  claimed  that  the  statistics  available  suggest  or  even 
prove  the  generalizations  submitted,  but  they  do  at  least  give 
them  verisimilitude. 

DENSITY 

The  aggregation  of  population  in  cities,  diminishing  as  it  does 
the  per  capita  allowance  of  sun  and  air,  must  tend  to  increase 
consumption. 

In  the  cities  of  8000  inhabitants  and  over  in  the  registration 
states  the  mortality  from  consumption  in  1900  was  fifty-three 
per  cent  higher  than  in  the  rural  districts.  The  towns  of 
25,000  inhabitants  or  more  in  the  state  of  New  York  have  a 
death-rate  from  this  disease  not  far  from  twice  as  great  as  the 
rest  of  the  state.  Lagneau  has  shown  that  in  France  the  mor- 
tality from  tuberculosis  varies  directly  according  to  the  size  of 
the  city,  from  490  deaths  per  100,000  living  in  Paris  to  181  in 
the  ninety-five  cities  of  less  than  5000  inhabitants. 

This  strict  correspondence  between  size  and  mortality  would 
be  expected  only  in  an  old  country,  comparatively  uniform  in 
the  composition  of  its  population,  its  industries,  the  develop- 
ment of  its  civic  conscience,  and  its  attitude  toward  sanitation. 
Mere  size,  the  number  of  persons  included  within  the  municipal 
boundary,  could  not  affect  the  health.  In  the  United  States, 
therefore,  the  number  and  variety  of  other  factors  prevent  the 
relation  noticed  in  France. 

The  tabulation  of  the  340  registration  cities  according  to  size 
(Table  16)  shows,  it  is  true,  that  the  cities  with  a  population  of 

74 


over  500,000  have  the  highest  mortality  both  from  all  causes 
and  from  consumption.  These  six  cities  have  doubtless  in  the 
highest  ratio  to  their  population  the  so-called  "slum"  con- 
ditions which  make  for  an  abnormal  amount  of  disease  and 
death.  The  other  groups  follow,  with  no  relation  between 
their  size  and  their  rank  according  to  death-rates.  The  most 
striking  thing  in  the  table  is  that  the  thirty-seven  cities  between 
50,000  and  100,000  inhabitants  rank  second,  having  both  a 
general  death-rate  and  a  consumption  death-rate  close  to  those 


Table  16. 


-Death-Rates  ix  the  340  Registration  Cities  of  the  United 
States,  Classified  According  to  Size 


0 

Size 

.a 
•2° 

3 

a, 
0 

Number  of 
Deaths 

De.a.th-Rates 
Per  10,000 

POPUL.ATION 

o«-2 
vX  a 

III 

V  'i  c 

H  2  0 

From 

all 
Causes 

From 
Con- 
sump- 
tion 

From 

all 
Causes 

From 
Con- 
sump- 
tion 

m 

^  0  <u 

S.2 

6 

13 
19 
37 
52 
213 

500,000  inhabitants  and  over. 
200,000-500,000  inhabitants. . 
100,000-200,000           " 
50,000-100,000           " 
25,000-50,000 
8,000-25,000           " 

8,074,561 

3,721,248 
2,412,538 
2,53g,68i 
i,go3,222 
3,073,182 

157,494 

70'930 
40.538 
48,700 
30,960 
53i737 

18,036 

7,698 
4o66 
5,571 
3,129 
5,33° 

195.1 
igo,6 
168.0 
191.8 
162.7 
174.9 

22.3 

20.7 
18.9 
21. 9 
,6.4 
17-3 

11-45 
10.85 
11.26 
11.44 
10.01 
9.92 

I 
3 
4 

6 
5 

Total  registration  area 

28,807,269 

512,669 

54,898 

178.0 

IQ.I 

10.69 

of  the  six  great  cities.  By  combining  groups  2  and  3  and 
groups  5  and  6,  the  cities  assume  the  following  rank  from  the 
standpoint  of  both  death-rates  : 

I — Cities  of  500,000  inhabitants  and  over. 

2— Cities  of  50,000  to  100,000  inhabitants. 

3 — Cities  of  100,000  to  500,000  inhabitants. 

4 — Cities  of  8000  to  50,000  inhabitants. 

This  invites  seductively  to  the  drawing  of  inferences  not 
justified  by  the  facts  at  command.  If  groups  2  and  3  could 
change  places  it  would  look  as  if  the  evil  sanitary  conditions 
popularly  ascribed  to  city  life  were  in  direct  proportion  to  the 
size  of  the  cities, — that  they  are  scarcely  noticeable  in  towns  of 
less  than  50,000,  and  that  they  reach  their  maximum  in  the 

75 


largest  cities.  In  groups  as  large  as  these  the  accidental  varie- 
ties of  industrial,  climatic,  and  racial  conditions  may  be  disre- 
garded on  the  ground  that  they  cancel  one  another  within  the 
group.  The  only  other  factor  to  be  considered,  then,  would  be 
the  agencies  counteracting  the  evil  tendencies  of  city  life.  Can 
these  figures  mean  that  in  the  United  States  cities  are  generally 
allowed  to  attain  a  considerable  size,  100,000  or  more,  before 
the  public  realizes  the  housing  problem,  the  drainage  problem, 
the  water  and  milk  supply  problems,  the  street-cleaning  prob- 
lem, and  others,  that  have  been  growing  up,  and  sees  its  re- 
sponsibility for  them?  The  intensity  of  the  bad  conditions  in 
the  six  largest  cities  would  explain  their  rank,  without  dis- 
crediting the  efforts  of  the  municipal  government.  But  the 
main  conclusion  to  be  drawn,  if  the  premises  may  be  accepted, 
is  that  the  small  city  of  between  50,000  and  100,000  inhabi- 
tants is  large  enough  to  have  its  serious  sanitary  problems, 
and  that  it  has  not  yet  realized  their  gravity.  These  figures 
will  have  served  their  end  if  they  add  volume  to  the  warning 
which  has  begun  to  sound,  that  the  small  city  would  do  well 
to  look  at  once  to  its  housing  conditions  and  other  matters 
connected  with  the  general  health  while  it  can  do  preventive 
and  constructive  work. 

On  account  of  their  interest  as  facts,  not  for  any  value  in 
throwing  light  on  the  influence  of  city  conditions,  the  mortality 
rates  are  given  for  the  twelve  largest  cities  in  the  United  States, 
from  all  causes  and  from  consumption  (Table  17  and  Diagram 
X.). 

Between  the  highest  and  the  lowest  death-rate  from  con- 
sumption, there  is  a  difference  of  almost  150  per  cent.  The 
variations  displayed  in  the  diagram  could  be  fully  explained 
only  by  a  careful  investigation  into  such  circumstances  as  the 
climatic  and  sanitary  conditions  of  each  city,  the  composition 
of  its  population  as  to  race,  sex,  and  age,  the  industrial  situa- 
tion, and  the  method  of  registering  deaths.  It  is  probable, 
however,  that  the  large  negro  element  in  New  Orleans  and  the 
Chinese  population  of  San  Francisco  would  go  far  toward  ac- 
counting for  their  position  at  the  head  of  the  list.      The  rank 

76 


according  to  the  consumption  death-rate  does  not  always  cor- 
respond to  its  rank  according  to  the  general  death-rate,  New 
Orleans  and  Buffalo,  in  fact,  being  the  only  instances  where  it 
does.  San  Francisco  and  Pittsburg  are,  perhaps,  the  most 
notable  examples  of  disparity  between  the  two  rates.  In  San 
Francisco,  with  a  high  mortality  from  consumption,  the  gen- 
eral death-rate  is  not  much  above  the  average.  In  the  case  of 
Pittsburg,  which  has  a  high  general  death-rate,  but  a  very  low 
mortality  from  consumption,  pneumonia  figures  as  the  chief 
cause  of  death,  and  consumption  causes  less  than  seven  per 
cent  of  the  total  number  of  deaths.  There  seems  to  be  no 
relation  between  the  death-rate  from  consumption  and  the  size 
of  the  city. 

Table  17. — Mortality  Rates  in  the  Twelve  Largest  Cities  of  the 

United  States,  1901 


Rank  According  to 
Mortality  from 
Consumption 

Cities 

Death-rate  per 

1,000  from  all 

Causes 

Death-rate  per 

1,000  from 
Consumption 

Per  Cent  of  all 

Deaths  Caused  by 

Consumption 

Rank  According 
to  General 
Death-rate 

Rank  According 

to  Population, 

1900 

I 

2 

3 
4 
5 
6 

New  Orleans 

San  Francisco 

Boston 

21.24 

19.34 
19.70 
20.00 
18. 88 
18.26 
19.96 

17-73 
16.21 
20.01 
17.08 
14.68 

3.18 
2.64 

2.35 
2.30 
2.29 
2.23 
2.16 
1.88 
1.78 
1.36 
1.32 
T.29 

14.9 
13.6 
II. 9 

II. 5 
12. 1 

12.2 
10.8 
10.6 
II. 0 

6.8 

7.7 
8.7 

I 
6 
5 
3 

r 
s 

12 

9 

5 

I 

New  York 

Cincinnati 

10 

Philadelphia 

3 
6 

7 
8 

Baltimore 

St.  Louis 

9       :      4 

II                       2 

9 
10 

'  Chicago   

'  Pittsburg 

2 

10 

12 

II 

II 

7 
8 

12 

Buffalo    

'  Death-rates  for  1900. 

Density  of  population,  however,  is  one  of  the  most  important 
factors  in  the  prevalence  of  tuberculosis,  and  if  statistics  on 
this  point  were  available,  a  direct  correspondence  would  prob- 
ably be  seen  to  exist. 

London   statistics   show   that    the    consumption    death-rate 

77- 


varies  according  to  the  number  of  persons  to  a  room,  and  in 
Dundee  it  has  been  found  that  it  varies  inversely  as  the  num- 
ber of  rooms  to  an  apartment.  Dr.  Korosi  of  Budapest  found 
that  consumption  caused  over  twenty-two  per  cent  of  all 
deaths  among  the  poor,  but  only  sixteen  per  cent  among  the 


1 

5- 

10 

/^ 

iio 

WB^/'AAy-'vC 

mmm. 

'myMM 

1 

)fl^^////7// 

w//Mm, 

w//Mm. 

mA 

r'~ 

ll^B;%J^>';:% 

y/</^'''/////////. 

y/////////////. 

'mM////^. 

^^ 

WK'^    / ',  '■    -■-,;2^ 

W/////y///y, 

^ 

1 

m^y///////A  v/////////////. 

y/////////wy. 

'm^A 

■■I^   ■ 

^  ^  ■  r  -•■^ 

f                1 

■■■ 

! 

^^^ 

H^H' 

,\ 

f 

^t^K^/^^/^/'y 

'my///M. 

w//xy/ym 

W/M///A 

\ 

■■1  ^ 

■' 

■  -  :    -5^ 

1 

^^^1  >#^/r 

^y^^Mm^^, 

W////</////a 

^/M^/z/m 

1 

Ih^^K'//;^ 

y/y///////A 

v/^/////////. 

w//////////;^ 

J^ 

r 

6 

10 

z-? 

so 

^ei^lTC^LfmLalliLiUix^ 


/r^u. 


(UHJUUufl^ 


H^ 


a-s- 


Diagram  X 


well-to-do.  While  no  such  figures  are  available  for  an  Ameri- 
can city  it  is  well  understood  that  consumption  is  pre-eminently 
a  disease  of  the  tenements.  This  does  not  follow  from  mere 
density  of  population  but  from  the  attendant  evils  of  poverty, 
ignorance,  and  carelessness,  all  of  which  operate  to  produce  a 
physical  condition  predisposed  to  the  disease,  as  well  as  to 
preserve  rather  than  destroy  the  specific  cause. 

78 


HABITS  AND  SOCIAL  CUSTOMS 

Of  almost  equal  importance  with  housing  conditions  and 
occupation  in  determining  the  prevalence  of  consumption  are 
habits  outside  of  working  hours.  Alcoholism  is  admitted  by- 
all  authorities  to  be  an  important  factor  in  predisposing  to 
tuberculosis.  Since  this  view  has  obtained  credence  the  story 
of  the  sport-loving  English  gentleman,  whose  recovery  was 
formerly  attributed  to  the  regular  imbibing  of  seven  tumblers 
of  punch  every  night,  is  quoted  as  evidence  of  the  value  of 
duck-shooting  and  angling  in  the  treatment  of  this  disease. 
The  susceptibility  of  cab-drivers  to  consumption  is  now  ex- 
plained, not  by  their  exposure  to  the  weather,  but  by  the  in- 
temperance which  characterizes  them  as  a  class.  For  frequenters 
of  saloons  the  weakening  effect  of  alcohol  on  the  system  is 
supplemented  by  exposure  to  a  germ-laden  atmosphere. 

It  has  been  estimated  that  the  excessive  use  of  alcohol  triples 
the  susceptibility  to  consumption.  The  effect  of  other  forms 
of  dissipation  has  not  been  stated  with  such  precision,  but  it  is 
none  the  less  true  that  any  habit  that  tends  to  lessen  the 
vitality  and  impair  the  physical  condition  increases  the  mor- 
tality from  consumption. 

The  question  of  amusement  is  also  a  most  important  one. 
If  the  New  York  printer,  for  example,  spends  his  evenings  in 
the  park  or  in  taking  a  long  walk,  and  his  Sundays  and  holidays 
in  excursions  to  the  sea  shore  or  the  country,  he  is  doing  much 
to  lower  the  probabilities  that  he  will  succumb  to  the  disease; 
if,  as  is  the  rule,  such  forms  of  recreation  have  no  attraction  in 
comparison  with  the  saloon  and  the  theatre,  he  can  hardly  hope 
to  escape.  The  air  in  many  dance  halls  and  theatres  where 
tenement  dwellers  seek  their  recreation  is  no  less  vitiated  than 
that  of  the  saloons.  Out-door  amusements  would  go  far  to- 
ward counteracting  insanitary  conditions  of  home  and  work- 
room. 


79 


IV 

VARIATIONS  IN  PREVALENCE  ACCORDING  TO  LOCALITY 
IN  THE   UNITED  STATES 

The  geographical  incidence  of  consumption,  far  from  intro- 
ducing a  new  causal  factor  into  the  field,  makes  demands  on 
all  causes  for  an  explanation  of  its  variations.  Each  social 
phenomenon  added  to  the  list  of  circumstances  which  affect 
the  prevalence  of  the  disease  takes  away  from  natural  and 
climatic  conditions  a  corresponding  part  of  the  responsibility 
popularly  assigned  to  them.  Their  influence  can  be  justly 
estimated  only  when  all  the  social  factors  can  be  eliminated. 

The  tendency  among  physicians  is  to  assign  to  climate  a  less 
and  less  prominent  place  in  the  list  of  causes.  Even  if  all 
investigations  did  not  combine  to  support  the  belief  that  its 
influence  is  insignificant  in  comparison  with  that  of  social  con- 
ditions, the  tendency  to  disregard  it  would  still  be  justifiable, 
since  climate  can  be  only  slightly  modified  by  man,  and  com- 
paratively few  persons  are  in  a  position  to  select  the  variety  in 
which  they  live,  while  many  of  the  social  conditions  found  to 
be  most  potent  factors  are  under  his  control. 

The  shaded  map  of  the  United  States  (Diagram  XI.)  shows 
the  percentage  of  mortality  due  to  consumption  in  each  state. 
The  ratio  to  the  population  would  be  a  preferable  basis  of  com- 
parison in  this  connection,  but  such  ratios  are  quite  unreliable 
outside  the  nine  registration  states  on  account  of  the  admit- 
tedly incomplete  record  of  deaths.  The  percentage  which 
deaths  from  consumption  make  of  the  total  number  of  deaths 
is  not  equally  unreliable,  since  there  is  nothing  which  would 
tend  to  make  the  ratio  of  omissions  greater  in  one  disease  than 
in  another.  The  proportion  of  deaths  caused  by  any  one  dis- 
ease is  probably,  therefore,  approximately  the  same  among  all 
the  deaths  reported  as  it  is  among  all  the  deaths  that  occurred. 
Diagram  XII.  arranges  the  states  in  order,  from  California 
with  its  15.46  per  cent  to  Utah,  with  only  4.64  per  cent. 

To  account  for  all  these  variations,  or  even  fully  for  any  one 

80 


81 


o 


X 


3.7lnnc8s«c  ^ 
X^tatky  ^^ 
V. South  "JtaJcdTA"^^ 

r  Oregon  "ij 

;  tni'Mrm.  i 

^South  Cirelina^ 

A  Ijetaware  ^ 
llColanra.ie  i 

tfMUT^Iani         ] 

V.DTmon  • 

^.  Mjnneeoft         * 

*4sNew%rJi       jj 

3/  Missoun  ; 

»  WorWi  latofi  ;^ 

■•K.tfew  Jersey  ^ 
«!5ZB>i»a«  Istani  ; 
<aC<!ii7iMr>eufi5 


9«  Loiiisiara 
Ac  VAseonsin 
*StMoin» 

SsOJk/ahoma 
•  SX'ttrmonJ 
%  Kansas 
W.7e>a> 
1^  "Pennttftntii 
3J.  Hortda 

Ife  Arkansas 
W  MflTiTana 
•«.  Michigan 
».  Wt^ratAo 
««loiira 
M:  Uafie 
WE.  Wyoming      -- 
»7.  Ii>aiaa  1*n>    ,^ 


S 


^ 


82 


of  them,  would  require  intimate  acquaintance  with  local  con- 
ditions and  medical  science,  and  would  fill  volumes.  It  would 
entail  explanations  for  the  prevalence  of  all  other  diseases,  as 
well,  since  an  abnormal  amount  of  heart  disease,  for  instance, 
or  malarial  fever,  would  lower  the  percentage  for  consumption. 

One  thing  at  least  is  evident.  In  all  the  states  which  have 
had  the  reputation  of  a  favorable  climate,  consumption  has  an 
importance  among  causes  of  deaths  far  above  its  average  im- 
portance in  the  country.  The  healthful  natural  conditions 
bring  this  about  in  two  ways :  they  keep  the  general  mortality 
low,  thus  giving  consumption  a  chance  for  prominence ;  and 
the  invalids  attracted  from  other  parts  of  the  country  raise  the 
proportion,  both  by  their  own  deaths  and  by  spreading  infec- 
tion. Davos-Platz,  in  Switzerland,  is  the  classic  example  of 
a  naturally  favored  spot  which  has  become  infected  by  out- 
siders. Colorado  and  Southern  California  are  showing  evi- 
dences of  concern  about  their  situation.  It  is  the  scattered, 
independent  invalids  who  do  the  harm ;  a  properly  conducted 
sanatorium  is  innocuous. 

Aside  from  the  possession  of  a  favorable  climate,  the  char- 
acteristics which  tend  to  raise  the  percentage  are  the  predomi- 
nance of  manufacturing  over  agricultural  pursuits;  a  large 
number  of  cities ;  a  relatively  large  proportion  of  men  and  of 
both  men  and  women  in  the  middle  age-periods ;  large  elements 
of  such  races  as  are  peculiarly  susceptible  to  this  disease.  The 
states  at  the  head  of  the  column  have  a  varying  number  of 
these  characteristics  in  varying  intensity,  while  a  composite  of 
those  at  the  other  end  would  bring  out  the  opposite  type. 

For  purposes  of  reference  Table  i8  has  been  compiled,  giving 
for  each  state  as  many  of  the  co-operating  factors  as  can  con- 
veniently be  expressed  in  percentages. 


83 


Table  i8. — Importance  of  Various  Elements  in  the  Population  of  the 
States  and  Territories  of  the  United  States,  1900 


2 

3 
4 
5 
6 

7 
8 

9 
10 
II 
12 
13 
14 
15 
16 

17 

18 

19 
20 


23 
24 

25 
26 

27 
28 

29 
30 
31 
32 

33 
34 
35 
36 

37 
38 

39 
40 

41 

42 
43 
44 
45 
46 

47 
48 

49 


States  Arranged  as  in  Diagram  XII 


California 

Tennessee 

Kentucky 

South  Dakota. . . 
West  Virginia. . . 

Nevada 

Virginia 

Oregon 

Indiana 

South  Carolina. . 

Arizona 

Delaware 

Colorado 

Washington 

Maryland 

North  Carolina. . 

Illinois 

Ohio 

Minnesota 

New  York 

Missouri 

North  Dakota.. . 

Mississippi 

Massachusetts. . . 

Alabama 

New  Jersey 

Rhode  Island. . . 

Connecticut 

Georgia 

Louisiana 

Wisconsin 

Maine 

Oklahoma 

Vermont 

Kansas 

Texas 

Pennsylvania .. . . 

Florida 

New  Hampshire 

Arkansas 

Montana 

Michigan 

Nebraska 

Iowa 

Idaho 

Wyoming 

Indian  Territory 
New  Mexico. .  .  . 
Utah 


:;d  d 


43- 

13- 

16. 

2. 

7. 

14. 

23. 
24.2 

7.5 

41.4 

38.1 

31-9 
46.9 

5-1 
47-1 
38.5 
26.8 
68.5 
30.8 
3-0 
2.6 
76.0 

7-3 
61.2 
Si. 2 
53-2 


24.1 


25.2 


55-3 
50.5 
50.8 
53.8 
52.1 
60.5 
49-9 
56.3 
5I-I 
49.6 

58.4 
5I.O 
54-7 
58.7 
49.6 
49.6 

51-3 
50.6 
53-2 
49-7 
51-4 
55-6 
50.4 
48.7 
50.1 
50.0 
49.1 
50.0 
49.8 
50.3 
51.6 
50.5 
53-8 
51.Q 
52.3 
51.8 
50.8 
52.1 
49-9 
51-5 
61.6 

51.6 
52.9 

51.8 
57-7 
62.9 

53-3 
53-4 
51-2 


f^fco 


21.3 
0.9 

2.3 
22.0 

2.4 
20.3 

i.o 
13.0 

5.6 

0.4 
18.2 

7.5 
16.8 

19.7 

7.9 

0.2 

20.0 

II. o 

28.8 

26.0 

6.9 

35-3 

0.5 

29.9 

0.8 

22.8 

31.2 

26.1 

0.6 

3-7 
24.9 

13.4 

3.9 

13.0 

8.6 

5.8 

15.6 

3.7 

21.4 

I.I 

25.6 

22.3 

16.6 

13-7 

13-5 

17.9 

1.2 

6.8 

19.1 


5-5 

23.8 

13-3 

5.2 

4-5 

16.4 

35.7 
4.6 

2.3 

58.4 
24.4 
16.6 
2.0 
4.2 
19.8 

33-3 
1.8 

2.3 
0.8 

1.5 
5-2 
2.3 

58.7 
1-3 

45-3 
3-8 
2.2 
1.8 

46.7 

47-2 
0.5 
0.3 
7.7 
0.3 
3.7 

20.4 
2.5 

43-7 
0.2 

28.0 
7.0 
0.9 
0.9 
0.6 
4-5 
3.8 

22.8 
7.7 
1-5 


'  "  Urban"  includes  cities  of  8,000  inhabitants  and  over. 
84 


IN    NEW    YORK    CITY 

The  wards  of  every  city  show  variations  as  wide  as  do  the 
states  of  the  country. 

Table  19. — Density  of  Population  and  Death-Rates  from  Consumption 
IN  Manhattan,  by  Wards,  i8go  and  1900 


Mortality  from 

Popula- 

Density of  Population 

Consumption 

Number  of 

Death-rate 

Ward 

tion, 

Persons 

0)  ■^ 

per  100,000 

1900 

per  Acre 

0   . 

Population 

^S,i     0^ 

1S90 

1900 

1890  1 

1901 

I 

9.516 

84.53 

72.31 

14.44 

641.38 

459.60 

28.34 

2 

1,488 

it.47 

18.37 

60.17 

776.26 

255.43 

67.09 

3 

1,797    39-63 

18.92 

52.23 

45S.34 

241. II 

47-39 

4 

19,554:214.57 

235-59 

9.80 

657-37 

506.25 

22.99 

5 

8,298;   73.72 

49-39 

33  00 

509.94 

490. 8 1 

3-75 

6 

20,004  297.73 

267.11 

10.29 

5 75 -S3 

517.98 

10.04 

7 

89,237289.73 

478.10 

65.02 

373-15 

155.96 

58.20 

8 

29,059' 170.60 

158.79 

6.92 

499-74 

319.06 

36.16 

9 

59,650  170.15 

1S6.48 

9.60 

388.55 

403.36 

3.81 

10 

71,8791523.60 

653-45 

24.80 

306.80 

201.02 

34-48 

II 

99-144 

384.S3 

515.30 

33.90 

327-5S 

136.10 

58.45 

12 

476,602 

51-73 

100.95 

95.15 

286.70 

187.23 

34.69 

13 

64,117 

428. 82 

599.22 

39.74 

284.12 

102.28 

64.00 

14 

34,035 

292.65 

354.53 

21. 14 

504.61 

267.62 

46.96 

15 

24,066 

133-78 

126.73 

5.27 

436.40 

288.37 

33.92 

16 

52,808 

140.79 

151. 31 

7.47 

377.10 

321.30 

14.80 

17 

130,796 

321.87 

40S.10 

26.79 

359-19 

239.93 

33.20 

18 

61,325 

145-30 

140.83 

3.08 

391.16 

346.88 

11.32 

19 

257,448 

178.21 

195-37 

9.63 

280.77 

256.91 

8.50 

20 

89,798 

189.93 

203. 68 

7.24 

430.86 

376.06 

12.72 

21 

60,211 

153-33 

146.50 

4.45 

373-38 

408.91 

9-51 

22 

189,261 

129.95 

160.83 

23.76 

319.52 

270.21 

15-43 

Manhattan 

1,850,093 

128.29 

165.32 

28.86 

341.00'' 

250.00^ 

26.69* 

^Average  for  the  six  years  ending  May  31,  1900. 
Statistics  of  New  York  and  Brooklyn^  pp.  250,  251. 
'  Manhattan  and  Bronx. 


U.  S.  Census,  1890,    Vital 


The  table  for   Manhattan    (19)    shows   for   each    ward   the 

85  • 


density  and  the  consumption  death-rate  and  the  increase  or 
decrease  in  both  respects  since  1890.  The  comparison  of  the 
rates  now  with  those  ten  years  ago  will  be  discussed  in  another 
connection. 

The  maps  (XIII.)  show  the  relation  between  density  of  popu- 
lation and  death-rate  from  consumption.  They  reveal  an 
anomalous  situation,  which,  if  passed  without  comment,  would 
surely  destroy  all  credence  in  certain  assertions  that  have  been 
made  in  the  foregoing  pages.  In  the  face  of  this  testimony  it 
requires  some  temerity,  and  a  mind  sibi  conscius  recti,  to  repeat 
that  density  of  population  is  a  potent  factor  in  the  prevalence 
of  tuberculosis.  Incontrovertibly  it  is,  and,  "other  things, 
being  equal,"  it  would  explain  the  variations  in  any  city.  But 
"other  things"  have  a  way  of  never  "being  equal,"  and  in 
New  York  City  they  develop  their  characteristic  inequality  to 
the  highest  degree. 

The  correspondence  which  would  be  expected  is  found,  to 
be  sure,  in  a  very  general  comparison  of  the  upper  and  lower 
sections  of  the  city ;  in  both  maps  all.  the  heavy  shading  is  be- 
low Fortieth  Street.  But  going  farther,  and  taking  the  lower 
half,  ward  by  ward,  the  alternatives  present  themselves  of  de- 
nying to  density  any  influence  whatever  or  of  concluding  that 
it  is  a  powerful  advantage.  It  sounds  paradoxical,  but  doubt- 
less if  it  were  possible  to  go  still  farther  and  compare  smaller 
areas  than  wards,  some  rational  relation  would  be  apparent. 
There  are  other  things  to  be  said  in  explanation  of  this  lack  of 
correspondence  between  density  and  death-rate :  first,  that  in 
many  of  the  down-town  wards,  where  the  tenements  are  being 
displaced  by  business,  the  actual  density  of  the  part  of  the  ward 
that  is  used  for  residence  purposes  is  far  greater  than  is  indi- 
cated by  the  average  number  of  persons  per  acre ;  and  second, 
and  most  important,  that  the  racial  factor,  with  all  that  it  im- 
plies of  social  and  industrial  characteristics,  overshadows  the 
influence  of  density. 

It  is  the  large  Hebrew  element  in  the  tenth  ward,  for  ex- 
ample, which  gives  this  notoriously  congested  spot  a  com- 
paratively   low  rate    of   tuberculosis.      For  the    same  reason 


FT^       /n-  /9f'      •       '       - 

■■       *<»  -  fff 
-■■■        Sia    OeJL-    nvu^    •     ' 


ID  ''^  "^fei_  So  Jiin^  /oimi  -iima 

Wl  ^  -     Sf        ■     /isac      • ' 

H.  30  —     3f          -     /i>f!n      • 

HI  Vo   -   ¥.f.         •.   /f^»i     - 

■i  TO    -    ■^f        -    /asm     • 


Diagram  XIII.      Manhattan  by  Wards 


87 


the  seventh,  eleventh,  and  thirteenth,  which  rank  next  the 
tenth  in  density,  have  the  very  least  consumption.  In 
the  first  ward,  where  the  average  density  per  acre  is  low, 
the  density  per  room  is  without  doubt  very  high,  since  much 
of  its  area  is  occupied  by  warehouses  and  other  buildings 
devoted  to  business  purposes.  The  houses  occupied  as 
dwellings  are  old  and  unimproved.  This  is  the  site  of  the 
Syrian  colony  ;  the  other  people  are  chiefly  Irish.  These 
are  the  most  glaring  discrepancies  between  density  and 
death-rate. 

The  reasons  for  the  high  consumption  rates  in  the  sixth  and 
fourth  wards  are  not  far  to  seek.  The  sixth  contains  China- 
town, and  the  rest  of  the  ward  is  made  up  chiefly  of  solid  tene- 
ment blocks  of  the  same  general  type  as  the  two  that  were 
razed  some  ten  years  ago  in  Mulberry  Bend.  The  fourth 
ward,  where  consumption  is  almost  as  bad,  is  one  of  the  oldest 
and  most  insanitary  districts  in  the  city.  The  main  element 
in  the  population,  moreover,  is  the  lowest  type  of  Irish- 
Americans,  whose  physical  constitutions  are  weakened  by  ex- 
cesses of  all  sorts  on  their  own  part  and  that  of  their  parents. 
Housing  conditions,  together  with  a  considerable  Irish  element 
probably  have  much  to  say  in  the  ninth  and  twenty-first  wards  ; 
and  there  are  large  negro  colonies  in  the  sixteenth  and 
twentieth. 

These  are  only  a  few  suggestions  :  sufficient  data  for  authori- 
tative explanations  do  not  yet  exist.  The  records  of  the  Tene- 
ment House  Department,  if  the  present  system  is  continued, 
will  within  a  few  years  supply  many  of  the  deficiencies. 

In  New  York  City  a  system  of  voluntary  notification  of  liv- 
ing cases  of  tuberculosis  was  instituted  by  the  Departrnent  of 
Health  in  1894.  Since  1897  all  institutions  and  physicians 
have  been  "required  "  to  report  such  cases.  The  reports  from 
institutions  are  practically  complete,  and  the  compliance  of 
physicians,  though  still  far  from  universal,  is  steadily  increas- 
ing. From  this  registration  of  living  cases  and  from  the 
records  of  deaths,  we  find  that  not  only  is  consumption  more 
prevalent  in  certain  parts  of  the  city  than  in  others,  but  that 

88 


in  any  given  district  it  is  concentrated  in  certain  streets,  blocks, 
and  even  houses.  There  are  houses  in  which  cases  of  con- 
sumption have  occurred  in  each  of  the  last  nine  years.  There 
are  others  in  the  same  block  from  which  none  have  been  re- 
ported. 


CHINESE 


Diagram  XIV 


Illustrations  of  this  distribution  by  houses  are  given  in  the 
accompanying  maps  (numbers  XIV.,  XV.,  XVI.,  XVII., 
XVIII.).      Each  locality  selected  for  this  purpose  is  of  a  dis- 


SYRIANS 


^'^X 

"1    1    ' 

■- 

-d 

J—?  ■  1 

WASHIUCTOH 


CTEENWICH 

Diagram  XV 


tinct  national  type,  and  has  had  the  same  racial  characteristics 
for  at  least  the  last  ten  years.  This  does  not  mean  that  all 
the  cases  noted  in  the  Italian  district  were  Italians,  but  that  in 

89 


in-    _  f— 1     Tl     nr, 1    .       J_ 

_      >'.c 

;_3 

-i-r 

ff?' 


EH 


->ffl 


■^- 


^^ 


IRISH 
Diagram  XVI 


Diagram  XVII 
90 


all  probability  most  of  them  were.  In  a  rough  way  the  number 
of  cases  on  these  maps  varies  according  to  the  death-rate  by 
nationality,  the  Chinese  district  being  far  and  away  the  worst 
of  all,  while  the  Hebrew  section  shows  only  a  few  cases.  Each 
letter  on  these  maps  represents  one  case  of  consumption  re- 
ported to  the  Health  Department  since  1894;  a  represents  a 
case  in  1894,  b  a  case  in  1895,  and  so  on  to  i,  a  case  in  1902. 
The  record  of  another  block,  one  in  the  worst  Irish  district,  is 
displayed  in  the  same  way  in  connection  with  Mr.  Poole's  ac- 
count of  Tlic  Plague  in  its  Stronghold. 

HEBREWS 


iL 

:  :lf 

-  1 

"     1     1 

*  — 

-i— 

— ^ — 1 1 

'^-^ 

trmi 

wSlr^ 

1  ^  <^.,'.  j,% 

PITT  STREET 


-t; 

'r.i^' 

a 

7 


Diagram  XVIII 


One  house  in  Chinatown  has  a  record  of  thirty-seven  cases 
in  the  nine  years  ;  another  of  twenty-iive ;  still  another  of  nine- 
teen. A  house  in  the  Syrian  quarter  shoAvs  thirteen  cases. 
There  are  sixteen  houses  in  a  single  block  in  the  fourth  ward, 
a  district  formerly  frequented  by  Irish,  now  being  displaced  by 
Italians,  from  which  123  cases  have  been  reported  since  1894. 
While  the  recurrence  of  cases  of  tuberculosis  in  the  same  house 
is  presumptive  evidence  of  house  infection,  still  the  burden  of 
proof  rests  on  scientific  experiments.  Experiments  proving 
the  virulence  of  dust  taken  from  apartments  that  had  been  oc- 
cupied by  consumptives  have  been  made  by  many  scientists  in 


many  countries.  Famous  examples  of  infected  institutions  are 
afforded  by  the  health  statistics  of  the  Catholic  Nursing  Orders 
in  Prussia  and  of  insane  asylums  and  prisons  in  the  United 
States  and  Europe,  and  many  physicians  have  recorded  their 
experience  of  individuals  or  families  attacked  by  phthisis,  when 
the  disease  could  be  attributed  to  no  other  cause  than  the  oc- 
cupancy of  rooms  which  had  been  infected  by  a  consumptive. 
The  fact  of  house  infection  has  been  proved.  Its  signifi- 
cance is  felt  as  yet  only  vaguely.  If  it  were  fully  realized  a 
frequent,  thorough  cleaning  of  every  apartment  occupied  by  a 
consumptive  would  be  insisted  on.  The  thought  that  the 
germs  of  tuberculosis  lurking  in  crevices  of  woodwork  and 
pores  of  plaster  are  threatening  the  health  of  one  family  for 
two  years  or  more  is  sufficiently  disquieting.  But  in  the  tene- 
ments, where  the  mobility  of  population  is  so  great  that  a  hun- 
dred persons  may  easily  occupy  the  same  rooms  in  the  course 
of  two  years,  the  danger  to  the  public  from  house  infection  as- 
sumes appalling  proportions. 

V 

VARIATIONS   IN  THE   RATE  OF  IMPROVEMENT  BETWEEN  189O 

AND    1900 

Conspicuous  as  this  disease  is  among  the  causes  of  mortality, 
a  comparison  of  the  death-rate  now  with  that  of  twenty  or 
thirty  years  ago,  or  even  ten,  shows  a  decided  improvement. 

Table  20.— Decrease  in  General  and  Consumption  Death-Rates  in  the 
Registration  Area,  iSgo-igoo 


Rates  Per  10,000 
Population 

Per  Cent 

OF 

1890 

1900 

Decrease 

196.5 
24-5 

178.0 
19. 1 

9-4 

Death-rate  from  consumption 

22.4 

92 


The  general  mortality  rate  is  also  falling,  and  this  is  more  sig- 
nificant when  it  is  remembered  that  the  registration  of  deaths 
was  far  less  complete  at  former  census  years  than  in  1900,  and 
that  the  improvement  in  the  accuracy  of  the  records  would 
tend  to  raise  the  death-rate.  Between  1890  and  1900  the  gen- 
eral death-rate  in  the  registration  area  (see  Table  20)  fell  9.4 
per  cent.  The  decrease  in  the  death-rate  from  consumption 
was  out  of  all  proportion  to  this,  being  22.4  per  cent.  The 
comparison  suggests  either  that  special  causes  have  been  at 
work  to  reduce  the  amount  of  consumption,  or  that  consump- 
tion is  a  disease  peculiarly  susceptible  to  every  improvement 
in  sanitary  conditions.  Both  explanations  bear  inspection. 
Doubtless  the  education  of  the  popular  mind  in  regard  to  the 
real  nature  of  consumption,  which  has  been  going  forward  in- 
cidentally through  the  general  diffusion  of  scientific  knowledge, 
as  well  as  by  the  specific  efforts  of  several  societies  and  some 
Boards  of  Health,  has  had  its  influence.  The  advance  in 
professional  knowledge  about  methods  of  treating  this  par- 
ticular disease,  and  the  increased  hospital  and  sanatorium  fa- 
cilities for  sufferers  from  it,  are  other  factors.  But  it  is 
also  probable  that  every  effort  for  more  healthful  conditions 
reduces  the  death-rate  from  consumption  more  than  that 
from  any  other  disease  of  adult  life,  and  that  even  measures 
directed  specifically  against  some  other  disease,  by  raising 
the  general  average  of  health  and  vitality,  contribute  to  the 
same  end. 

Just  as  consumption  is  not  distributed  impartially  among  all 
elements  in  the  population,  so  the  decrease  in  the  death-rate 
is  not  going  on  uniformly  in  these  elements.  The  rate  of  im- 
provement varies,  like  the  prevalence  of  the  disease,  with  age, 
sex,  and  locality,  and  probably,  though  there  are  no  figures  to 
substantiate  the  assumption,  also  with  nationality  and  occupa- 
tion. In  these  variations  are  to  be  found  both  indications  as 
to  where  the  most  vigorous  action  is  called  for  and  ground  for 
the  hope  that  all  effort  will  be  worth  while. 

It  is  seen  from  Table  21  (Diagram  XIX.)  that  the  rate  of  im- 
provement between  1890  and  1900  was  greater  by  five  per  cent 

93 


Zoom 


30 

irfo 

fm 

f^/o 

mo 

A 

J^o 

-?(? 

B 

A 

/a 

ft 

/o 

..J..  ,    .u       ,    ,            ---'^^■^ 

'"**  V                * 

«                     V 

•\. 

\ 

~-A-fi 

\2o%       \^o^  B-JB  ,/ZUUL. 


Diagram  XIX.     Death-Rate  from  Consumption 


94 


in  the  cities  than  in  the  rural  part  of  the  registration  area. 
This  means  that  if  the  same  rate  of  decrease  should  go  on  in 
both  sections  until  1920  the  death-rate  would  then  be  higher 
in  the  country  than  in  the  cities.     The  explanation  is  found  in 

Table  21. — Dfxrease  in  Consumption  Death-Rate  in  the  Urban  and  the 
Rural  Population  of  the  Registration  Area,  i8go-igoo 


Death-Rates  Per  10,000 
Population 

Per  Cent 

OF 

1890 

I  goo 

Decrease 

Registration  cities , 

29.4 
18. 1 

20,5 
13.4 

30.22 
25.91 

Rural  part  of  registration 

states  

the  awakening  of  the  municipal  conscience  to  its  responsibilities 
in  the  matter  of  the  public  health.  It  is  pleasant  to  contem- 
plate that  in  the  cities,  where  the  rate  is  highest,  it  is  falling 
the  most  rapidly.  But  the  situation  does  not  justify  an  un- 
troubled complacency ;  it  holds  the  warning  that  a  passive  atti- 
tude toward  this  serious  problem  cannot  be  maintained  with 
impunity  by  even  small  towns  and  country  districts. 

The  next  table  (22)  and  diagram  (XX.)  are  concerned  with 
New  York  City.     As  would  be  expected  from  the  foregoing 


Table  22. — Death-Rates  in  New  York  City  and  in  the  United  States  in 
Certain  Years  between  1881  and  1902 


Year 

Death-Rates  Per  10,000  in 
Manhattan  and  Bronx 

Death-Rates  Per 
10,000  FROM  Con- 
sumption IN  the 
United  States 

Consumption 

Bronchitis  and 
Pneumonia 

1881 
1890 
1900 
1902 

42.7 
34-1 
25.7 
22.5 

48.4 
43-2 

23.0 
17.4 

95 


'^oMs  ^  /?r/-  /fa  I 


■SZ) 

tF77) 

/Ffo 

/fc 

^ 

C 

s. 

A 

\ 

\ 
\ 

C 

?«- 

N 

\ 

?0 

?•*■ 

N 

f^" 

£ 

V 

fs- 

'"•♦^ 

I 

/o 

5- 

^ 


.^ 


.^ 


.3a 


A 


.S^ 


./7 


JO 


Diagram  XX 


96 


comparison  of  cities  in  general  with  rural  districts,  the  decrease 
in  New  York  proper,  the  most  essentially  urban  spot  in  the 
United  States,  is  greater  than  the  decrease  in  the  country  as  a 
whole.  The  third  line  in  the  diagram  was  added  in  considera- 
tion of  the  claim  frequently  made,  and  discussed  in  the  early 
pages  of  this  report,  that  the  decrease  in  the  death-rate 
from  consumption  is  largely  a  matter  of  false  registration, 
and  that  it  is  found  to  be  counterbalanced  by  an  increase 
in  the  death-rates  from  pneumonia  and  bronchitis.  These 
rates,  too,  it  is  evident,  are  decreasing,  and  that  fast  enough 
to  make  it  necessary  to  look  elsewhere  than  to  false  records 
for  a  complete  explanation  of  the  improvement  in  regard  to 
tuberculosis.  The  rate  of  decrease  in  New  York  has  been 
unusual,  even  admitting  that  it  has  not  been  quite  so  great  as 
the  figures  indicate,  and  there  are  enough  conspicuous  reason^ 
for  it  on  the  surface  to  arouse  disappointment  that  it  was  not 
still  greater. 

Since  1890  there  has  been  a  decided  improvement  in  the 
general  sanitary  condition  of  the  city;  the  streets  now  are 
actually  cleaned ;  several  small  parks  have  been  introduced  in 
the  most  crowded  districts,  displacing  some  of  the  worst  tene- 
ment blocks;  recreation  piers  have  been  built ;  the  milk  supply 
has  been  brought  under  supervision ;  medical  inspection  has 
been  established  in  the  public  schools ;  a  corps  of  physicians 
under  the  direction  of  the  Board  of  Health  visits  the  tenements 
systematically  every  summer.  The  work  of  the  Tenement 
House  Department,  by  far  the  most  important  new"  influence 
on  the  generalsanitary  condition,  began  in  1902,  and  its  effect 
is  therefore  only  beginning  to  be  felt.  Besides  the  municipal 
activities  there  has  been  an  enormous  development  of  private 
organizations  which  concern  themselves,  directly  or  indirectly, 
with  the  health  of  the  poor.  All  of  these  efforts  for  improving 
the  general  health  increase  the  average  power  of  resistance  to 
the  tuberculosis  germs. 

There  has  also  been  evolved  by  the  Department  of  Health, 

under  the  direction  of  Dr.   Hermann  M.  Biggs,  a  system  for 

reducing   the  danger  of    infection  by  destroying  the    germs. 
7 


In  1889  the  consulting  pathologists  of  the  Board  of  Health, 
Dr.  Prudden,  Dr.  Loomis,  and  Dr.  Biggs,  submitted  a 
report  on  the  causation  and  prevention  of  pulmonary  tu- 
berculosis, with  suggestions  as  to  the  most  profitable  lines 
of  municipal  intervention.  It  seems  curious,  now  that  bo- 
vine tuberculosis  is  regarded  as  a  comparatively  unimportant 
source  of  infection,  that  the  first  result  of  this  report  was  to 
convince  of  the  necessity  for  controlling  the  milk  and  meat 
supply. 

In  1894  the  other  recommendations,  with  additions,  were 
put  into  effect.  The  registration  of  living  cases  was  begun,  by 
respectfully  requesting  physicians,  and  requiring  institutions, 
to  report  all  cases;  later,  in  1897,  it  was  made  the  "duty  "  of 
physicians.  Compliance  has  been  secured  from  institutions 
by  following  them  up  with  postals  and  inspectors.  Circulars 
were  sent  at  the  beginning  to  all  the  physicians  in  the  city,  call- 
ing attention  to  the  new  requirement ;  an  increasing  observance 
of  it  is  secured  from  them  by  sending  a  minatory  letter  to  every 
physician  who  reports  a  death  from  tuberculosis  not  previously 
registered,  asking  how  it  happened,  and  leaving  the  impression 
that  the  omission  would  better  not  occur  again.  In  1894,  too, 
the  systematic  distribution  of  circulars  of  information  to  con- 
sumptives was  begun.  The  circulars  were  in  simple  language, 
in  English  on  one  side,  with  a  German,  or  Italian,  or  Yiddish 
translation  on  the  obverse.  They  have  been  distributed  in  the 
tenements  ever  since,  at  the  rate  of  20,000  to  50,000  per  year, 
by  the  medical  inspectors. 

Out  of  respect  to  the  wishes  of  physicians,  and  on  the  pre- 
sumption that  they  will  give  their  patients  all  necessary  in- 
struction, no  inspection  is  made  of  private  cases  reported.  An 
inspector  is  sent  to  every  address  reported  by  an  institution  to 
give  instructions,  in  case  of  a  living  patient,  about  the  care  of 
the  sputum;  in  case  of  a  death  or  a  removal,  to  make  "such 
recommendations  as  seem  to  him  necessary  to  render  the  habi- 
tation free  from  danger  of  infection."  When  the  inspector 
recommends  renovation,  an  order  is  issued  on  the  landlord : 
new  tenants  are  not  allowed  to  move  in  until  the  order  has 

98 


been  complied  with.  At  present  either  renovation  is  ordered, 
or  the  premises  are  disinfected  with  formaldehyde  and  the 
bedding  with  steam  after  every  death  or  removal.     The  work 


Table  23. — Death-Rate,  Number  of  Deaths,  and  Other  Data  Concerning 
Tuberculosis  in  the  City  of  New  York  from  1881  to  1902 


I. — Manhattan  and  the  Bronx 


Year 

General 
Population 

Total 

Deaths 

from 

All 

Causes 

1-  •— ' 

V 

c 
0 

0  0  y 

°        r= 

6 

0    0) 

P 

ifp 

0 

<  S  0 
^P^ 

B 
e5.2 

P 

Total  Number  of 
Cases  of  Tubercu- 
losis Reported,  in- 
cluding Duplicates 

3 
P 

ii 

Is 

1881 

1,244,511 

38,624 

31.04 

6,123 

4.92 

5,312 

811 

15.85 

4.27 

1882 

1,280,857 

37,924 

29.61 

6,052 

4.72 

5,247 

805 

15.96 

4.10 

1883 

1,318,264 

34,011 

25.80 

5,943 

4-51 

5,290 

65^ 

17-47 

4.01 

1884 

1,356,764 

35,034 

25.82 

6,039 

4-45 

5,235 

804 

17.28 

3-86 

1885 

1,396,388 

35,682 

25-55 

5,945 

4.26 

5,196 

749 

16.66 

3-72 

1886 

1,437,170 

37,351 

25-99 

6,349 

4.42 

5,477 

872 

16.99 

3-81 

1887 

1,479,143 

38,933 

26.32 

6,007 

4.06 

5,260 

747 

15-43 

3.,56 

1888 

1,522,341 

40,175 

26.39 

6,073 

3-99 

5,260 

813 

15.12 

3-46 

1889 

1,566,801 

39,679 

25.32 

6,041 

3.86 

5,179 

862 

15.22 

3-30 

i8go 

1,612,559 

40,103 

24.87 

6,409 

3-97 

5,492 

917 

15-98 

3-41 

1891 

1,659,654 

43,659 

26.31 

6,109 

3-. 56 

5,160 

949 

13-99 

3-" 

1892 

1,708,124 

44,329 

25-95 

6,061 

3-55 

5,033 

1,028 

13-67 

2-95 

1893 

1,758,010 

44,486 

25.30 

6,163 

3-5' 

5,124 

1,039 

13-85 

2.91 

1894 

1,809,353 

41,175 

22.76 

5,720 

3.1b 

4,658 

1,062 

13.89 

2-57 

4,166 

511 

i8q=; 

1,873,201 

44,420 

23.18 

6,283 

3-35 

5,205 

1,078 

14.47 

2.7H 

5,824 

1,147 

1896 

1,906,139 

41,622 

21.84 

5,926 

3-" 

4,994 

932 

14.24 

2.62 

8,334 

1,856 

1897 

1,940,553 

38,877 

20.03 

5,791 

2.98 

4,843 

948 

14.89 

2.50 

9,735 

2,703 

1898 

1,976,527 

40,438 

20.46 

5,901 

2.99 

4,957 

944 

14-59 

2.51 

10,798 

2,239 

2,920 

1899 

2,014,330 

39,9" 

19.81 

6,209 

3.08 

5,238 

971 

15-56 

2.60 

10,484 

2,472 

3,115 

1900 

2,053,979 

43,227 

21.04 

6,179 

3.01 

5,278 

901 

14  29 

2.57 

9,639 

2,436 

3,512 

igoi 

2,095,686 

43,307 

20.66 

6,049 

2.89 

5,233 

816 

13-97 

2.50 

12,135 

3,005 

4,397 

igo2 

2,139,632 

41,704 

19.49 

5,744 

2.68 

4,893 

851 

13-77 

2.29 

13,383 

3,738 

4,631 

II. — Greater  New  York 


1898 

3,272,418 

66,224 

20.26 

9.265 

2.69 

7,724 

1,541 

13-97 

2.25 

3,945 

1899 

3,356,722 

65,344 

19.47 

9,575 

Z.70 

8,016 

1,559 

14.65 

2.26 

4,500 

igoo 

3.444,675 

70,872 

20.57 

9,630 

2.80 

8,154 

1,476 

13-59 

2-37 

14,433 

2,456 

5,289 

1901 

3,536,517 

70,717 

20.00 

9,389 

2.65 

8,135 

1,254 

13.28 

2.30 

17,588 

4,191 

6,744 

1902 

3,632,501 

68,112 

18.7s 

8,883 

2.45 

7,571 

1,312 

13-44 

2.08 

16,614 

4,268 

7,820 

begun  by  the  Board  of  Health  in  1894  included  also  arrange- 
ments for  the  free  bacteriological  examination  of  sputum,  in 
order  that  physicians  might  be  facilitated  in  their  diagnosis. 
In  1902,  7820  specimens  were  examined.  Table  23,  which  has 
just  been  published  by  the  Department  of  Health,  gives  in 

99 


compact  form  a  comprehensive  view  of  the  course  of  the 
death-rate  and  the  increase  in  registration  and  bacteriological 
work. 

In  1896  the  system  was  completed  by  the  enactment  of  an 
ordinance  against  indiscriminate  expectoration.  This,  the 
iirst  of  its  kind  in  America,  was  supplanted  by  a  set  of 
resolutions  adopted  at  a  meeting  of  the  Board  of  Health 
in  June,  1902,  in  consequence  of  a  communication  from 
Dr.  Biggs. 

By  these  resolutions,  spitting  is  prohibited  on  any  sidewalk ; 
on  the  floor  of  any  common  hall  in  any  tenement-house ;  of 
any  common  hall  or  office  in  a  hotel  or  lodging-house ;  of  any 
theatre,  or  of  any  building  in  which  there  is  a  public  assemblage 
of  people,  or  upon  the  floor  of  any  public  conveyance,  or  of 
any  ferry-house,  depot,  station  platform,  or  stairs  of  any  ele- 
vated railroad  or  other  common  carrier.  Spitting  into  the 
street  from  any  public  conveyance  is  also  prohibited.  The 
resolutions  require  that  copies  be  displayed  in  "sufficient 
number  "  in  all  places  affected  by  the  new  rules,  and  that  the 
owners  or  managers  of  such  places  provide  "sufficient  and 
proper  receptacles  for  expectoration,  and  also  .  .  .  pro- 
vide for  the  cleansing  and  disinfection  of  said  receptacles  at 
least  once  every  twenty-four  hours."  The  providing  of 
"proper  receptacles  for  expectoration,"  in  the  proportion  of 
one  for  each  two  persons,  is  also  made  mandatory  on  every 
corporation  or  person  engaged  in  the  manufacture  of  cigars, 
cigarettes,  or  tobacco,  or  conducting  the  business  of  printing, 
when  ten  or  more  persons  are  employed  on  the  premises. 

The  only  public  places  where  expectoration  may  now  be 
deposited  with  the  sanction  of  the  law  are  the  streets 
between  the  curbs,  and  the  walls,  ceilings,  and  furniture 
of  buildings  and  conveyances.  Sputum  on  the  street  beyond 
the  sidewalk,  where  it  is  exposed  to  the  action  of  the  sunlight, 
is  regarded  by  Dr.  Biggs  as  an  inconsiderable  source  of  danger. 
That  the  explicit  inclusion  of  walls  and  furniture  has  been 
found  not  unnecessary  is  evidenced  by  the  phrasing  of 
the  Cambridge  regulation,   in  which  "any    other  part"   of  a 

100 


public  conveyance  is  declared  taboo  as  well  as  the  floor  and 
platform. 

The  effect  which  a  rigid  enforcement  of  these  resolutions 
would  have  in  diminishing  tuberculosis  is  no  less  patent  than 
the  advantage  from  an  aesthetic  standpoint.  Unfortunately 
the  conspicuous  placards  have  still  too  little  deterrent  effect, 
and  arrests  are  made  only  spasmodically. 

The  strong  point  in  the  New  York  system  is  its  educational 
feature.  The  inspectors  often  find,  on  visiting  a  new  case, 
that  the  general  principles  are  already  understood.  The  fol- 
lowing postal,  received  at  the  Health  Department  from  an 
East  Side  tenement,  gives  evidence  of  an  accurate  idea  of  the 
cause  of  consumption,  as  well  as  of  society's  responsibility  in 
regard  to  its  prevention : 


"Sirs: 

"A  tenent  by  the  name  of  D at  the  premises  of  - 

A Street,  room ,  has  a  boarder  by  the  name  of  A- 


B who  has  consumption.      This  man  where  he  goes  spits. 

And  the  party  he  boards  at  has  six  children.     Please  see  that 
he  is  taken  out.      By  so  doing  oblige, 

"Neighbor." 

There  is  still  a  third  explanation  for  the  unusual  decrease  in 
the  consumption  death-rate  in  New  York  City.  This  will  take 
some  of  the  glory  from  the  two  already  discussed, — the  general 
sanitary  improvement,  and  the  specific  measures  of  the  Board 
of  Health  against  consumption  —  since  it  is  a  circumstance 
quite  outside  the  influence  of  the  city  government  or  of  private 
philanthropy.  It  depends,  in  fact,  on  nothing  less  remote  than 
the  economic  and  social  conditions  of  Europe  and  the  United 
States  and  our  hospitable  attitude  toward  immigrants ;  and  it 
is  the  change  that  has  resulted  in  the  racial  composition  of 
New  York's  population  from  the  changes  in  the  character  of 
our  immigration.  It  happens  that  the  nationalities  which  are 
pouring  into  the  United  States  are  the  very  ones  least  subject 

101 


to  tuberculosis.  The  Italians,  Russians,  Hungarians,  and 
Poles,  who  have  the  lowest  death-rates  from  consumption, 
formed  only  7.37  per  cent  of  the  population  of  the  city  in 
1890.  In  1900  their  number  was  more  than  three  times  as 
large  and  amounted  to  16.34  per  cent  of  the  population.  The 
proportion  of  the  peoples  whose  death-rate  from  consumption 
is  higher  than  that  of  the  native  white  population  of  native 
parentage  has  correspondingly  decreased,  so  that  in  1900  they 
formed  only  45.8  per  cent  in  comparison  with  56.6  per  cent 
in  1890.  The  change  in  the  relative  size  of  the  two  groups 
has  been  going  on  since  1900  even  more  rapidly.  This  alone 
would  operate  to  lower  the  amount  of  tuberculosis  in  the  city. 
That  some  part  of  the  reduction  in  the  death-rate  from  con- 
sumption, even  if  it  cannot  be  exactly  computed,  is  thus  at- 
tributable to  immigration,  must  be  conceded.  Evidently  the 
influx  from  southern  and  eastern  Europe  is  not  to  be  depre- 
cated on  the  ground  that  it  intensifies  and  complicates  this 
problem. 

In  this  connection  reference  should  be  made  again  to  Table 
19,  in  which  a  comparison  of  1901  with  1890  is  made  by  wards. 
The  factor  of  nationality  is  of  importance.  Without  recourse 
to  this  explanation  it  would  be  hard  to  understand  why  in 
the  seventh  ward,  where  the  density  has  increased  65  per 
cent,  more  than  in  any  other  ward  below  Eighty-sixth  Street, 
the  consumption  death-rate  has  decreased  58  per  cent.  But 
the  people  who  have  been  crowding  into  this  already  over- 
crowded district,  as  well  as  into  the  eleventh  and  thirteenth 
wards,  where  the  decrease  in  consumption  has  been  even  more 
remarkable,  are  chiefly  Russians,  Roumanians,  and  Poles. 
It  is  the  character  of  the  population  again  which  must  ac- 
count for  the  small  improvement  in  the  fourth  ward  with 
its  slight  increase  in  density,  and  in  the  sixth,  where  there 
has  actually  been  a  decrease  of  ten  per  cent.  In  regard  to 
the  two  wards  where  consumption  has  increased,  the  ninth 
and  the  twenty-first,  whatever  change  there  has  been  in  the 
population  would  not  account  for  it.  It  is  probable  that  in 
both  districts  there  has  been  less  improvement  in  housing  con- 

102 


%inu</L.  /^  e'^)ni/^ki^i^t£ck  u^  fr  fm^  <yf  ^^:a^c4£6di^_^ 


Diagram  XXI 


103 


ditions  than  there  has  been  in  many  other  tenement  sections. 
This  would  be  a  partial  explanation,  but  a  more  thorough 
investigation  is  called  for  than  has  yet  been  made  into  the 
causes  of  a  situation  so  out  of  harmony  with  the  general 
tendency. 

The  point  of  chief  interest  in  any  comparison  of  rates  of 
decrease  is  whether  or  not  the  improvement  has  corresponded 
to  the  need.  This  can  be  best  seen  in  Diagram  XXL,  in 
which  the  wards  are  arranged  according  to  the  position  they 
occupied  in  1890  and  according  to  the  rate  of  improvement 
since  then. 

Leaving  out  of  consideration  the  second  and  third  wards, 
where  the  figures  are  too  small  to  be  significant,  there  are  few 

Table  24. — Death-Rates  Per  10,000  Population  From  Consumption  in  the 
Registration  Area,  by  Age-Period  and  Sex,  in  1890  and  in  1900 


Age 

Males 

Females 

1890 

1900 

1890 

1900 

I  '^—AA  years 

32.5 
38.5 
41. 0 

26.5 
29.1 
29.4 

31.6 

25-5 
33-2 

24.0 

4.^-64.     "     

17.3 
23.0 

65  years  and  over 

exceptions  to  the  general  rule  that  the  wards  with  the  highest 
death-rates  in  1890  show  a  low  percentage  of  decrease,  while, 
conversely,  the  wards  with  a  conspicuous  decrease  are  those 
which  had  a  low  rate  in  1890.  In  other  words,  the  improve- 
ment has  been  where  it  was  least  urgently  needed,  and  the 
worst-infected  spots  are  not  changing  their  character  with 
any  rapidity.  Any  disposition  to  rest  content  with  what 
has  already  been  accomplished  in  New  York  City  must  be 
disturbed  by  the  reflection  that  such  conditions  persist  as 
are  found  in  the  fourth  and  sixth  wards,  and  that  in  the 
ninth  and  twenty-first,  each  with  a  population  of  60,000,  con- 
sumption is  increasing. 

104 


K 


TP 


.1 


105 


The  differences  in  the  present  sex  and  age  incidence  of  con- 
sumption assume  a  new  importance  when  their  tendencies  are 
examined.  The  rate  of  improvement  during  the  last  decade 
among  men  and  women  at  three  age-periods  is  shown  in  Table 
24  and  Diagram  XXII. 

At  all  three  ages  the  women  began  with  lower  rates  in  1890, 
and  in  1900  were  still  in  advance  of  the  men.  The  advantage 
on  the  side  of  the  women  is  probably  due  to  three  facts :  that 
women  are  affected  more  quickly  and  more  directly  than  men 
by  any  advance  in  general  economic  prosperity ;  that  there 
has  been  more  improvement  in  the  housing  conditions  of  the 
mass  of  the  people  than  in  the  conditions  under  which  they 
work;  and  that  in  the  improvement  that  has  been  made  in 
industrial  conditions  the  chivalrous  principle  has  obtained  of 
protecting  women  first. 

To  indicate  more  clearly  the  differences  in  the  rate  of  im- 
provement all  the  lines  showing  the  decrease  between  1890 
and  1900  have  been  continued  in  the  diagram  to  the  zero  point. 
For  obvious  reasons  this  is  not  to  be  taken  as  in  any  sense  a 
prophecy  of  what  may  be  expected ;  it  is  not  to  be  assumed, 
on  the  basis  of  this  diagram,  that  by  the  year  1950  consump- 
tion will  have  disappeared  entirely,  as  a  cause  of  death.  The 
mortality  from  consumption  is  due  to  a  thousand  different 
causes,  varying  in  the  degree  of  effort  required  to  eradicate 
them.  The  less  obstinate  of  these  causes,  as,  for  instance, 
dirty  streets  and  windowless  bedrooms,  may  be  attacked 
directly.  They  have  already  been  attacked  in  New  York, 
and  remedial  measures  are  bringing  prompt  return.  Other 
causes,  such  as  a  physical  susceptibility  to  the  disease  in  large 
numbers  of  persons,  can  be  affected  only  by  slow  and  cir- 
cuitous processes,  and  it  may  well  be  that  the  total  eradica- 
tion of  consumption  is  impossible.  In  this  connection  it  is 
worth  while  to  remember  that,  after  all,  "to  travel  hopefully 
is  a  better  thing  than  to  arrive,  and  the  true  success  is  to 
labor. 

The  virtue  of  the  pseudo-prophetic  lines  is  simply  that  they 
offer  a  vivid  method  of  comparing  the  rates  of  improvement. 

106 


From  them  it  appears  that  if  the  rate  of  decrease  of  the  last 
decade  could  be  continued  there  would  be  no  deaths  from  con- 
sumption among  either  men  or  women  over  sixty-five  years  of 
age,  after  the  year  1925.  Among  women  between  forty-five 
and  sixty-five  years  of  age  this  cause  of  death  vanishes  even 
sooner,  in  1922,  but  among  men  of  the  same  age  it  persists 
ten  years  longer.  Among  both  men  and  women  between  the 
ages  of  fifteen  and  forty-five,  the  period  where  consumption  is 
now  the  most  important  cause  of  death,  the  rate  of  progress 
is  slowest.  Among  women  at  this  age  consumption  is  not 
eliminated  until  193 1,  among  men  not  until  1946.  The  point 
of  all  this  is  that  it  is  at  the  age  of  greatest  economic  and  social 
significance,  where  consumption  is  an  overwhelmingly  impor- 
tant cause  of  mortality,  that  the  rate  of  improvement  has  been 
the  slowest.  It  gives  pause  to  undue  complacency  over  results 
already  accomplished  by  suggesting,  as  did  the  analysis  by 
wards  of  the  decrease  in  New  York  City,  that  much  remains 
to  be  done. 

This  scrutiny  of  the  general  decrease  in  the  death-rate  from 
consumption  has  a  double  value.  The  analyses  by  wards  in 
New  York,  and  by  age  and  sex,  reveal  the  fact  that  there  are 
localities  and  elements  of  the  population  which  have  had  little 
share  in  the  general  improvement  that  has  been  going  on. 
The  coincidence  by  which  these  localities  and  elements  are  the 
very  ones  where  the  ravages  of  the  disease  are  the  worst  em- 
phasizes their  claim  to  first  consideration  and  to  individual 
treatment  in  the  efforts  for  further  progress.  At  the  same 
time,  the  superior  degree  of  improvement  in  the  cities  estab- 
lishes the  value  of  the  preventive  work  already  instituted, 
thereby  furnishing  a  stimulus  for  additional  and  specialized 
measures. 

VI 

SOCIAL  CONSEQUENCES 

Tuberculosis  is  a  social  disease  not  only  in  the  sense  that  its 
prevalence  and  its  persistence  depend  on  social  factors,  but 

107 


also  because  it  is  itself  a  factor  of  primary  influence  in  other 
social  problems. 

Its  relation  to  degeneracy  is  a  question  that  has  been  too 
little  investigated.  Evidence  is  not  lacking  that  the  children 
of  consumptives  are  below  the  average  of  physical  strength  and 
that  they  often  exhibit  psychical  peculiarities.  There  are 
statistics  indicating  that  consumptives  and  their  children  are 
more  liable  than  others  to  insanity  and  idiocy.  It  may  be 
that  the  modifications  of  temperament  wrought  by  the  disease 
may  tend  to  increase  certain  forms  of  immorality.  The  mental 
characteristics  popularly  recognized  as  accompanying  consump- 
tion have  frequently  been  used  in  fiction.  Their  dramatic  value 
is  unquestioned,  but  how  far  they  affect  the  practical  problems 
of  crime  and  dependency  due  to  mental  derangement  has  not 
yet  been  clearly  demonstrated.  These  are  questions  whose 
discussion  must  be  entrusted  to  experts  in  medical  and  psy- 
chical science. 

There  is  another  way  in  which  society  is  affected  by  con- 
sumption, quite  within  the  comprehension  of  the  lay  mind. 
It  means  an  enormous  loss  in  the  aggregate  productive  power 
of  the  social  body,  and  has  no  insignificant  place  among  the 
causes  of  poverty. 

The  Medical  Ofificer  of  Health  of  an  English  town  is  author- 
ity for  the  statement  that  if  phthisis  had  not  existed  as  a 
cause  of  death  every  person  born  in  England  and  Wales  in 
1 90 1  would  have  had  an  average  increase  of  two  years  and  a 
half  in  his  expectation  of  life,  and  that  the  working  period, 
from  fifteen  years  of  age  to  sixty-five,  would  have  been 
lengthened  by  nearly  two  years.  The  translating  of  human 
life  into  pecuniary  value  is  a  delicate  undertaking,  but  it  is  the 
most  striking  way  of  expressing  this  economic  loss.  Dr.  Her- 
mann M.  Biggs  has  estimated  that  the  total  annual  loss  to  New 
York  City  from  tubercular  disease  is  at  least  $23,000,000,  and 
that  the  loss  to  the  United  States  must  be  more  than  $330,- 
000,000. 

There  are  no  figures  to  indicate  the  amount  of  poverty  that 
is  due  to  consumption,  but  the  experience  of  charitable  socie- 

108 


ties  in  every  city  furnishes  examples  of  families  who  become  de- 
pendent from  this  cause.  Sickness  is  found  to  be  the  cause  of 
poverty  in  at  least  one  case  out  of  four.  The  long  duration 
of  consumption  and  its  liability  to  fall  on  the  chief  wage-earner 
of  the  family  tend  to  give  it  an  importance  as  a  cause  of  poverty 
out  of  all  proportion  to  its  importance  as  a  cause  of  death. 
Those  who,  although  self-supporting,  have  made  no  provision 
for  the  future,  are  easily  pushed  by  the  first  attack  of  this  dis- 
ease over  the  border-line  into  the  class  of  dependents,  while 
the  illness  of  the  chief  wage-earner  soon  eats  up  the  little  sav- 
ings of  the  most  provident  family,  and  even  when  a  subordi- 
nate member  is  the  victim  his  long  illness  becomes  too  serious 
a  drain  on  the  family's  earning  capacity. 

In  the  absence  of  statistics  on  this  point  illustrations  of  con- 
crete cases  may  be  taken  from  the  records  of  the  Charity 
Organization  Society  and  the  United  Hebrew  Charities  of  New 
York  City. 

A  native  American,  a  mechanic  of  forty-one,  with  a  wife  and 
three  small  children,  fell  ill  nine  months  ago.  Neither  the 
man  nor  his  wife  has  ever  been  strong,  but  he  is  honest  and  in- 
dustrious, and  had  always  supported  his  family.  They  applied 
for  help  while  the  disease  was  incipient,  were  helped  for  a  few 
weeks  until  the  man  found  work  that  was  easy  and  suitable, 
and  are  again  independent  except  for  the  milk  and  eggs  sup- 
plied for  the  man. 

Another  family  has  been  brought  from  comfort  to  a  re- 
luctant dependence  by  this  scourge.  The  head  is  an  Eng- 
lish silver-chaser,  incapacitated  for  his  trade  on  accoun-t  of 
age.  His  wife  is  a  delicate  woman  with  poor  eyesight.  One 
son  has  tubercular  abscesses.  A  daughter  died  of  consump- 
tion not  long  ago.  Another  son,  when  just  convalescent  from 
an  attack  of  typhoid  fever,  nursed  this  girl  through  her  last 
illness,  and  he  is  now  a  victim  of  consumption.  This  young 
man,  a  skilled  electrician,  was  the  main  support  of  the  family, 
and  his  illness  makes  it  necessary  that  they  should  receive 
charity. 

The  daughter  of  a  frail,  deformed  German  widow  was  forced 

109 


by  consumption  several  months  ago  to  give  up  her  work,  their 
only  source  of  income.  Another  German  widow,  blind  for 
four  years,  is  entirely  dependent  on  her  twenty-eight-year-old 
son,  who  has  recently  developed  consumption.  The  mother 
of  five  children,  all  under  thirteen,  is  caring  for  a  consumptive 
husband  and  doing  what  she  can  to  support  the  family  by  act- 
ing as  janitress. 

Last  January  a  combination  of  misfortunes  brought  the 
family  of  an  Irish  widow  and  her  five  children  under  the  care 
of  the  Charity  Organization  Society.  The  children  range  from 
thirteen  to  twenty-three  years  of  age,  and  all  of  the  older  ones 
have  received  a  good  education.  The  misfortunes  were  these  : 
the  two  grown  boys  were  temporarily  out  of  work,  one  by 
reason  of  an  accident  to  his  foot,  the  other  through  an  ill- 
advised  business  venture;  the  mother's  health  did  not  allow 
of  her  working  steadily.  As  the  seventeen-year-old  girl  was  a 
cripple,  and  the  fifth  child  only  thirteen  years  old,  the  main 
burden  of  the  family  had  fallen  on  the  oldest  girl.  She  had 
met  the  demand  by  work  in  a  department  store  and  later  in 
electrical  works,  but  at  the  expense  of  her  health.  She  de- 
veloped consumption  and  the  family  became  dependent  on 
charity. 

A  picture  too  often  paralleled  in  its  squalid  features  is  afforded 
by  the  case  of  a  white  woman  married  to  a  Chinese  laundry- 
man,  both  of  whom  have  consumption.  They  are  known  to 
have  lived,  since  1894,  in  seven  different  houses  in  Chinatown, 
all  undoubtedly  infected.  The  woman  was  found  a  few  months 
ago,  with  her  five  small  children,  in  one  of  the  two  dark,  damp 
rooms  which  are  their  home,  covering  cord  by  the  light  of 
a  kerosene  lamp  to  supplement  her  husband's  scanty  earn- 
ings. With  their  combined  efforts  they  would  be  unable  to 
maintain  life  on  even  this  low  plane  without  the  assistance 
of  friendly  neighbors,  the  husband's  "cousins,"  and  the 
Chinese  Mission. 

Suggestive  of  much  beside  the  point  in  hand  and  illustrative 
of  many  Hebrew  characteristics,  is  this  story  of  a  Russian 
peddler  who  died  a  few  months  ago.      He  had  just  succeeded 

110 


in  bringing  over  his  wife  and  two  children  when  the  hard  work 
and  privations  of  his  two  years  in  this  country  resulted  in  a 
physical  break-down  leading  into  consumption.  His  brother 
and  the  brother's  wife,  with  four  children  of  their  own,  offered 
the  hospitality  of  their  two-room  tenement  to  the  whole  family. 
There  they  all  lived  together,  the  two  men,  two  women,  and 
six  children,  through  the  months  of  the  invalid's  decline,  ask- 
ing help  from  no  one,  and  brought  to  the  notice  of  a  charitable 
society,  a  week  before  his  death,  only  by  the  report  of  a  neigh- 
bor. 

If  nothing  could  be  done  it  would  be  worse  than  useless 
to  dwell  on  the  ravages  of  this  disease.  But  it  is  admitted 
now  that  consumption  is  both  curable  and  preventable.  As 
its  prevalence  is  due  largely  to  social  conditions,  and  as 
it  in  turn  aggravates  social  evils,  so  its  prevention  depends 
chiefly  on  social  activity.  Its  complete  eradication  is  only 
a  matter  of  time  if  the  public  can  be  roused  to  a  sense  of 
its  responsibility.  Aside  from  the  humanitarian  considera- 
tions, it  is  palpably  of  interest  to  the  more  fortunate  part  of 
society  to  save  itself  from  the  consequences  of  a  neutral 
attitude. 

The  social  results  of  consumption  show  why  society  should 
be  concerned  to  eliminate  this  disease,  as  the  variations  in  in- 
cidence show  where  its  efforts  can  most  advantageously  be 
placed. 

VII 

CONCLUSION 

The  practical  application  of  the  facts  brought  out  by  the 
study  of  figures  is,  in  the  last  analysis,  the  only  justification  of 
such  a  study.  The  first  use  served  by  statistics  in  the  conflict 
with  consumption  was  to  attract  the  public  mind  by  merely 
showing  the  size  of  the  enemy.  The  necessity  for  decisive 
action  against  so  formidable  a  foe  has  been  impressed  on  every 
one  by  the  iteration  and  reiteration  of  statements  in  regard  to 

111 


the  death-rate  from  consumption.  I  think  we  may  assume  that 
this  fundamental  object  has  by  now  practically  been  accom- 
plished. 

The  next  use  is,  if  we  may  carry  on  the  military  figure,  to 
disclose  the  strategic  points  for  attack.  This  can  be  done  only 
by  an  analysis  of  the  gross  death-rate.  Such  an  analysis  shows 
that  among  men,  from  twenty  to  forty-five  years  of  age,  the 
situation  is  the  most  serious,  both  because  the  death-rate  now 
is  heavy  and  because  it  is  decreasing  more  slowly  than  in  other 
parts  of  the  population.  It  shows,  further,  that  the  city  is 
more  in  need  of  attention  than  the  country,  and  that  in  every 
city  certain  districts  and  even  certain  houses  are  worse  than 
others;  it  shows  that  the  Chinese,  negroes,  Bohemians,  and 
Irish  suffer  more,  and  are  consequently  a  greater  menace  in 
this  respect  to  the  community  than  the  Jews  and  the  Italians; 
and  that  special  efforts  are  called  for  in  behalf  of  persons  em- 
ployed in  certain  occupations.  By  regarding  these,  and  all 
other  indications  which  can  be  derived  from  the  available 
statistics,  the  campaign  can  be  conducted  economically, — 
attacks  can  be  made  where  the  minimum  of  effort  will  result 
in  the  maximum  of  success. 

It  is  from  the  natural  history  of  the  bacilhis  tuberculosis  that 
we  get  the  clue  for  the  specific  weapons  to  be  used  in  hunting 
it  down  and  exterminating  it.  Its  natural  history  teaches  that 
it  does  not  multiply  after  it  has  left  the  human  body  and  that  it 
may  be  killed  by  the  simplest  methods,  exposure  to  direct 
sunshine  being  the  surest,  while,  on  the  other  hand,  it  may 
retain  its  virulence  for  two  years  or  more  if  allowed  to  remain 
in  a  dark,  damp  corner.  The  weapons  indicated  are,  there- 
fore :  the  control  of  the  habit  of  indiscriminate  expectora- 
tion ;  the  disinfection  of  apartments  where  consumptives 
have  lived ;  the  education  of  all  members  of  society  in  the 
few  simple  facts  which  they  should  know  about  the  cause 
and  nature  of  consumption ;  and  the  multiplication  of  dis- 
pensaries, hospitals,  and  sanatoria,  to  care  for  persons  in  all 
stages  of  the  disease  who  cannot  otherwise  receive  proper 
treatment. 

113 


But  since  there  will  always  be  a  residuum  of  the  people 
who  either  through  ignorance  of  or  indifference  to  their  re- 
sponsibility in  this  matter  cannot  be  controlled,  the  effective 
campaign  must  go  much  farther.  It  must  concern  itself  with 
strengthening  the  defenses,  as  well  as  with  directly  attacking 
the  enemy.  And  just  here  the  "social  history"  of  the  bacillus 
again  becomes  valuable,  for,  in  addition  to  showing  the  im- 
portance of  the  enemy  and  the  strategic  points  for  attack,  it 
suggests  supplementary  means  for  carrying  on  the  campaign. 
It  points  to  the  fact  that  everything  that  can  be  done  to 
make  men  healthier  and  happier  is  germane  to  this  purpose 
of  preventing  tuberculosis.  The  improvement  of  the  housing 
of  the  working-classes  and  of  the  sanitary  conditions  of 
theatres  and  churches,  as  well  as  of  factories  and  shops ;  the 
multiplication  of  parks  and  play-grounds,  gymnasiums,  and 
baths;  the  widening  of  streets;  the  enforcement  of  a  standard 
of  healthful  conditions  in  all  occupations;  the  reduction  of  the 
working-day ;  the  raising  of  wages ;  the  education  of  the  wo- 
men and  girls  of  the  tenements  in  the  art  of  housekeeping  and 
the  science  of  food  preparation ;  the  crusade  against  the  noxious 
features  of  the  saloon ;  scientific  instruction  about  the  effects 
of  alcohol  in  the  public  schools — all  these  and  kindred  efforts 
tend,  less  indirectly  than  might  be  thought,  to  reduce  the 
death-rate  from  tuberculosis. 

In  fact,  the  trend  of  opinion  among  the  best  authorities 
seems  to  be  in  the  direction  of  emphasizing  more  and  more 
these  apparently  indirect  methods  of  dealing  with  the  problem. 

The  problem  would  soon  disappear  of  itself  if  it  were  possible 
for  everybody  to  breathe  fairly  pure  air,  to  keep  clean  with  a 
reasonable  effort,  and  to  have  enough  of  the  right  sort  of  food 
to  eat.  Theoretically  it  would  not  seem  extravagant  to  hope 
for  such  a  situation,  but  practically  it  will  require  vigorous 
action  along  all  the  lines  suggested,  and  more,  to  bring  it 
about. 

From  this  point  of  view  a  campaign  plan  so  extended  as 
to  include  attacks  on  all  the  problems  now  vexing  society  is 
less  beside  the  mark  than  it  may  seem  at  first  sight.     Its  very 

113 


comprehensiveness  is  its  most  valuable  feature,  since  it  serves 
to  emphasize  the  necessity  for  concerted  action,  and  suggests 
at  the  same  time  the  encouraging  reflection  that  every  bit  of 
social  effort  "works  together  for  good,"  whether  consciously 
or  not,  to  decrease  the  suffering  from  tuberculosis. 

The  idea  of  the  importance  of  co-ordinating  all  social  forces 
is  everywhere  finding  recognition.  Nowhere,  perhaps,  has  it 
been  more  definitely  and  more  significantly  expressed  than  at 
the  meeting  of  the  Central  International  Tuberculosis  Com- 
mittee in  Paris  last  May,  where  it  was  the  dominant  note 
through  all  the  proceedings.  It  was  particularly  well  put  by 
M.  Casimir-Perier  in  these  sentences  from  his  opening  address: 

"The  struggle  with  tuberculosis  is  intimately  bound  up  with 
the  solutions  of  the  most  complex  economic  problems,  and  no 
plans  will  be  complete  which  have  not  for  their  basis  the  ma- 
terial and  moral  improvement  of 'the  people.'  The  struggle 
with  tuberculosis  demands  the  mobilization  of  all  social  forces, 
public  and  private,  official  and  voluntary." 

"The  mobilization  of  social  forces"  is  a  phrase  that  merits 
adoption.  Doubtless  it  will  achieve  popularity  in  connection 
with  a  subject  where  the  military  metaphor  is  so  apposite 
that  honest  efforts  to  avoid  it  are  apt  to  result  only  in  fresh 
variants. 

It  is  not  surprising  that  the  French,  with  their  passion  for 
embodying  ideas  in  institutions,  should  be  the  first  to  apply 
this  one.  At  the  same  meeting  where  another  national  char- 
acteristic found  illustration  in  the  felicitous  phrase  of  the  ex- 
president  of  the  Republic,  Professor  Brouardel  announced  that 
in  France  the  project  had  been  conceived  of  forming  a  sanitary 
federation.  This  federation  will  include  societies  against  tuber- 
culosis and  against  alcoholism,  societies  for  improving  the 
housing  conditions  of  the  working  classes,  mutual  benefit  so- 
cieties, the  whole  teaching  force,  and  will,  in  short,  "constitute 
a  union  where  there  will  be  room  for  all  those  who  have  at 
heart  the  public  welfare,  the  health  of  the  people,  the  physical 
and  moral  betterment  of  their  fellow-men."  Such  a  sanitary 
federation,  if  extended  to  its  logical  bounds,  would  include  in 

114 


its  ultimate  membership  every  individual  in  the  nation  whose 
age  and  intelligence  would  allow  him  to  understand  the  object. 
It  may  be  a  far  cry  to  the  degree  of  enlightenment  and  sense 
of  responsibility  which  would  be  required,  but  none  the  less  all 
effort  directed  specifically  against  consumption  must  contem- 
plate as  its  final  object  the  erection  of  the  nation  into  a  Com- 
mittee on  the  Prevention  of  Disease  and  Allied  Evils. 


115 


Appendix  2 

SCHEDULE    FOR   RECORDING  THE  SO- 
CIAL HISTORY  OF  CASES  OF 
CONSUMPTION 


117 


SCHEDULE    IN    REGARD   TO   CONSUMPTIVES 

/.     Personal  Description. 

a.  Sex. 

b.  Date  of  birth. 

c.  Color. 

d.  Nationality. 

e.  Birthplace  of  mother. 

f.  Length  of  residence. 

1.  In  the  U.  S. 

2.  In  New  York  City. 

g.  City-bred  or  country-bred? 
//.     Family  Relations. 

a.  Single,  married,  widowed,  or  divorced? 

b.  Did  father  have  a  strong  constitution? 
Did  mother? 

c.  Did  father  drink? 

d.  Did  mother  drink? 

e.  Members  of  family  or  household. 


SEX 

DATE  OF 
BIRTH 

RELATIONSHIP 
TO    PATIENT 

I 

2 

3 
4 
5 
6 

7 
8 

119 


///.     History  of  Illness. 

a.  How  long  has  patient  been  ill? 

b.  Health  before  consumption  appeared. 

1.  Was  constitution  strong  or  weak? 

2.  Was  digestion  naturally  good,  indifferent,  or  poor? 

3.  Was  patient  well  nourished? 

c.  Stage  of  the  disease  reached  at  present. 

d.  Account  of  treatment  received,  with  results. 

1.  Patent  medicines. 

2.  Private  physicians. 

3.  Dispensaries. 

4.  Hospitals  and  sanatoria. 

IV.  Other  Cases  of  Consumption  among  Associates. 

(As  many  details  as  possible  of  the  history  of  each  case.) 

a.  Relatives. 

b.  Inmates  of  the  household. 

c.  Intimate  friends. 

d.  Other  tenants  in  the  same  house. 

V.  Housing,  when  the  Disease  first  Became  Apparent. 

a.  Lodging-house,  hotel,  boarding-house,  or  "at  home  "? 

b.  Home  conditions. 

r  I.   Number  of  families  in  the  house. 

Type  of  house  -<|  2.   Number  of  families  on  each  floor. 

y  3.   Front  or  rear  tenement. 

C  I.   On  which  floor? 

^        .     .         -  I  2.   Number  of  rooms. 

Description  of  tenement-^        ,^     , -i  ,  •  1  i-  1  x. 

■^         .  3.   Ventilation  and  light. 

[  4.   General  sanitary  condition. 

VI.  Recreation  before  Becoming  III. 

a.  What  did  the  patient  do  for  recreation? 

b.  Where  did  he  spend  his  evenings? 

c.  How  did  he  spend  Sunday? 

d.  What    places    of   amusement   did   he    frequent?      (Give 

addresses.) 


120 


CASES  OF 
CONSUMPTION 

AMONG 
FELLOW-WORKERS 

P< 
< 

w 
Pi 

UM0U5J 

jaquinjj 

WORK  DONE  BY 
PATIENT 

{SupsnBqxa 

3(J0AV    SE^ 

1 

Description 
of  work 

Length  of 

Time 
Employed 

smuoj\[ 

SJE3A 

H 

W 
IS 
>- 
O 
hJ 

PL, 

w 

o 

w 
o 

<i; 
i-j 

P 
W 
Ul 

PJ 
o 

H 
I? 

S 
H 
< 

P4 

O 

I— I 

K 
O 

o 
Pi 

ipasn 
suoo5)ids  aJSyW 

i  papiAOjd 
snooj;ids  S-ISAS. 

ssauijuBsp 

|BJ9U3Q 

t  uoijEipuaA 
aaqjo  Xuy 

i  uado  jd3>( 
SAvopuiAv  aj3^ 

SMOpuiAV 

JO  aaquinf^ 

azjS 

Suip^inq 
ui  uouBnjig 

w 

Q 

Q 

< 

(4 

-o 

4) 

s  =^ 

u   < 

S    c 

;-    o 

^^ 

3 

^    > 
„    o 

3    a 

•    o 

1-   *^-l 

- 

« 

m 

■* 

After  Becoming 
111  with 
Consumption 

si- 

•2  8 

o. 

121 


VIII.  Re c 07' d  for  Dependency. 

a.  Has  patient  ever  been  an  inmate  of  a  charitable  institu- 

tion, public  or  private? 
If  so, 

1.  When? 

2.  Where? 

3.  For  how  long? 

b.  Has  patient  ever  applied  for  aid  to  a  charitable  society  or 

individual? 

IX.  Has  Patient  ever  been  an  Inmate  of  a   Correctional  or 

Penal  Institution  ? 
If  so, 

a.  When? 

b.  Where? 

c.  For  how  long? 

d.  For  what  offence? 

X.  Dissipation. 

a.  Was   patient   an   occasional,    a  moderate,    or  a  "hard" 

drinker? 

b.  Had  intemperance  injured  the  constitution? 

c.  Other  forms  of  dissipation. 

XI.  Education. 

a.  General:  none,  poor,  fair,  good,  or  excellent? 

b.  Did  patient  ever  receive   instruction   in  physiology  and 

hygiene? 

XII.  Other  Information  not  Covered  by  Schedule  Inquiries. 

(Signed) 


123 


Appendix  3 

SOME  SOCIAL  ASPECTS  OF  THE 

TUBERCULOSIS  INFIRMARY 

BLACKWELL'S  ISLAND 

By  homer  folks 

commissioner  of  public  charities  of  the 

city  of  new  york 


133 


SOME  SOCIAL  ASPECTS  OF  THE  TUBERCULOSIS 
INFIRMARY,    BLACKWELL'S   ISLAND 

A  FEW  months  after  the  establishment  of  the  Tuberculosis 
Infirmary  at  Blackwell's  Island,  the  Commissioner  found  him- 
self in  some  uncertainty  as  to  the  value  of  the  institution. 
The  number  of  patients  discharged,  otherwise  than  as  im- 
proved, was  very  considerable,  and  neither  the  nurses  nor  the 
physicians  seemed  to  have  a  very  clear  idea  as  to  why  the 
population  changed  so  rapidly,  nor  as  to  just  how  much  was 
being  accomplished  for  the  patients  while  in  the  Infirmary, 
Principally  for  the  purpose  of  securing  a  better  insight  into 
the  actual  workings  of  the  institution  from  the  patient's  point 
of  view,  a  Deputy  Superintendent,  Mr.  Christopher  Easton, 
was  appointed  in  September,  1902,  with  instructions  to  give 
special  attention  to  personal  acquaintance  with  the  patients, 
to  the  social  life  of  the  institution,  to  its  economic  and  social 
features,  and  as  to  the  real  causes  of  so  great  a  change  in  the 
population  of  the  institution  from  month  to  month.  The  per- 
son appointed  was  taken  from  the  eligible  list  for  the  position 
of  Deputy  Superintendent  of  Hospitals,  and  had  not  had  pre- 
vious experience  in  institutional  or  hospital  work.  He  was  a 
graduate  of  Princeton  University,  and  brought  to  his  work  a 
well-trained  mind  and  a  marked  taste  for  the  study  of  social 
questions.  He  was  instructed  by  the  Commissioner  to  become 
personally  acquainted  with  each  patient  immediately  upon  his 
admission  to  the  institution,  to  secure  from  him  such  informa- 
tion as  might,  when  collated  with  hundreds  of  other  similar 
histories,  throw  light  on  the  general  question  of  the  efificient 

125 


treatment  of  the  tuberculosis  problem  by  municipal  and  private 
action.  He  was  instructed  to  explain  to  each  patient  the  ob- 
jects of  the  institution,  how  to  adjust  himself  to  the  life  of  the 
institution,  how  to  get  the  most  benefit  from  it,  and  how  to 
exercise  the  greatest  precautions  in  his  own  behalf  and  in  be- 
half of  the  other  patients.  He  was  to  give  each  patient  a  copy 
of  the  rules  of  the  institution  and  to  explain  their  purpose. 
He  was  also  to  encourage  the  patients  to  report  to  him  any 
matter  about  which  they  seemed  to  have  reasonable  cause  for 
complaint,  and  was  instructed  to  investigate  carefully  each 
such  complaint,  and  to  see  that  substantial  justice  was  secured. 
He  was  also  to  interview  each  patient  discharged  from  the 
Infirmary,  either  at  his  own  request  or  because  of  insubordina- 
tion or  misconduct,  or  as  apparently  cured,  and  was  to  keep 
full  records  showing  why  each  patient  left  the  institution,  and 
his  condition  on  leaving  as  compared  with  his  condition  on 
admission.  He  was  also  to  do  as  much  as  his  other  duties  per- 
mitted in  keeping  in  touch,  by  correspondence,  with  patients 
discharged  from  the  institution  as  improved  or  apparently  cured. 
The  Deputy  Superintendent  was  also  given  special  oversight 
over  the  sanitary  discipline  of  the  Infirmary,  the  daily  life  of 
the  patients,  all  questions  of  recreation,  games,  exercise  (under 
the  direction  of  the  physicians),  reading,  entertainments,  etc. 
A  very  complete  report  of  Mr.  Easton's  work  is  included  in 
the  annual  report  of  the  Department  of  Public  Charities  for 
1902,  pages  128  to  173.  This  report  includes  copies  of  the 
rules  of  the  institution  and  of  the  suggestions  to  patients 
leaving  the  Infirmary ;  it  also  includes  a  copy  of  the  schedule  of 
questions  adopted  upon  the  recommendation  of  the  Charity 
Organization  Society's  Committee  on  the  Prevention  of  Tu- 
berculosis. The  major  part  of  the  information  contained  in 
the  following  paragraphs  is  taken  from  Mr.  Easton's  report. 

The  schedule  in  regard  to  personal  history,  family  relations, 
history  of  disease,  etc.,  of  each  consumptive  is  quite  elaborate. 
Considerable  doubt  was  expressed  as  to  whether  the  patients 
would  be  willing  to  give  so  much  information,  or  as  to  whether, 
if  given,   it  would  be  given  grudgingly  and  with  bad  grace. 

126 


Mr.  Easton  finds,  however,  that,  as  a  rule,  the  patients  rather 
like  to  be  questioned,  and  are  not  only  willing,  but  glad,  to 
give  the  desired  information.  About  half  his  time  is  occupied 
by  interviews  with  patients,  either  just  after  admission,  or  in 
regard  to  suggestions  or  complaints  made  by  them,  or  when 
they  express  a  desire  to  leave  the  Infirmary. 

Comparatively  little  has  been  accomplished  in  the  way  of 
amusement  and  recreation,  partly  because  of  lack  of  place  for 
the  purpose,  partly  because  there  are  not  many  games  the  pa- 
tients care  for,  and  partly  because  complete  rest  is  for  many 
patients  the  best  possible  treatment.  The  general  tone  of  the 
place,  however,  is  decidedly  one  of  hopefulness  and  good 
cheer.  It  might  reasonably  be  expected  that  this  would  be 
the  least  cheerful  institution  in  the  Charities  Department.  On 
the  contrary,  the  impression  which  is  gained,  both  by  the 
casual  visitor  and  by  its  permanent  officials,  is  quite  the  oppo- 
site. This  I  attribute  in  part  to  the  fact  that  many  new 
methods  are  being  introduced,  and  that  they  tend  to  interest 
the  patients  and  encourage  them  to  believe  that  their  condition 
may  be  improved.  It  is  also  due  in  large  part  to  the  very 
valuable  work  done  by  Mr.  Easton  through  his  personal  re- 
lations with  the  patients. 

The  statistics  compiled  at  the  time  of  the  publication  of  the 
annual  report  cover  too  small  a  number  of  cases  to  have  any 
considerable  value.  They  are,  however,  extremely  interesting, 
and  suggest  that  similar  statistics,  covering  a  large  number  of 
personal  records,  would  be  of  very  great  value,  especially  in 
indicating  the  social  condition  and  factors  which  are  prominent 
as  causes  of  the  disease.  A  preliminary  schedule  was  adopted 
October  i,  1902,  and  used  for  the  first  186  admitted  after 
that  date.  The  regular  schedule  of  the  Charity  Organization 
Society's  Committee  was  thereafter  used.  The  statistics  in- 
cluded in  the  report  cover  only  100  cases  taken  on  the  new 
schedule. 

It  is  probable  that  the  information  entered  upon  the  sched- 
ules is  vastly  more  reliable  than  that  ordinarily  found  upon 
the  records  of  public  institutions.     The  first  statement  made 

137 


by  the  patients  was  not  entered  upon  the  blank  if  there 
seemed  to  be  any  doubt  of  its  truth,  but  by  skilful  questioning 
and  cross-questioning  every  effort  was  made  to  arrive  at  the 
actual  facts,  and  to  enable  the  patient  to  understand  why  the 
actual  facts  were  desired.  It  is  Mr.  Easton's  opinion  that  not 
much  information  of  importance  has  been  withheld  or  mis- 
stated after  such  inquiry. 

The  following  observations  are  based  on  the  first  one  hun- 
dred cases  for  whom  the  Charity  Organization  Society  sched- 
ule was  used.  The  average  duration  of  the  disease  before  the 
patient's  admission  to  the  hospital  was  seven  months,  twenty- 
one  days ;  the  average  period  of  unsteady  employment,  three 
years  and  four  months.  The  latter  figure  is  much  larger  than 
it  otherwise  would  be  by  reason  of  the  large  number  who  had 
been  unsteady  workers  owing  to  dissipation  or  some  cause  other 
than  consumption.  The  seven  months  and  twenty-one  days' 
duration  of  the  disease  prior  to  admission  to  the  Infirmary  is, 
on  the  other  hand,  probably  too  short.  Many  patients  have  not 
realized  their  condition  in  the  early  stages  of  the  disease.  The 
corresponding  period  of  the  patients  admitted  to  the  State 
Sanatorium,  Rutland,  Massachusetts,  is  stated  as  twelve  and 
one-quarter  months,  although  they  receive  a  more  incipient 
class  of  cases  than  does  the  Infirmary.  Almost  exactly  half 
of  the  patients  are  between  the  ages  of  thirty  and  forty-five. 
The  numbers  by  each  period  are  as  follows : 

Under  20 , I 

20  to  25 7 

251030 9 

30  to  35 15 

35  to  40 15 

40  to  45 19 

46  to  50 8 

51  to  55 12 

55  to  60 8 

60  to  65 6 

100 

Forty-one  per  cent  are  native-born  and  fifty-nine  per  cent 

foreign-born.     The  birthplace  of  the  mothers  of  the  patients 

shows  only  twelve  per  cent  native-  and  eighty-eight  per  cent 

foreign-born.     The  figures  in  detail  are  as  follows : 

128 


NATIVITY 


New  York  City 28 

United  States 13 

Ireland 21 

Italy .  4 

Canada ; 2 

Japan i 

Sweden 3 

Austria  ....    3 

Germany 6 

Bohemia i 


Switzerland i 

Russia 4 

Africa  (Liberia) i 

Scotland i 

England 5 

Holland i 

Hungary 2 

Poland 2 

Wales I 


BIRTHPLACE  OF  MOTHER 


New  York  City 4 

United  States 8 

Ireland 44 

Italy 5 

Canada i 

Japan 1 

France i 


England S 

Scotland i 

Russia 6 

Germany 12 

Austria 5 

Bohemia i 

Sweden 3 


The  figures  showing  the  occupations  of  the  patients  are  of 
little  value  except  as  indicating  the  very  wide  distribution  of 
such  occupations.     The  figures  are  as  follows : 


MAIN  OCCUPATIONS 


Waiters 

Outside  salesmen 

Sailors 

Postal  clerk 

Agent 

Chance  indoor  and  outdoor  workers 

Machinist 

Butcher 

Cook 

Cigar-box  maker 

Longshoremen 

Plasterers  

Stone  setter , 

Unskilled  outdoor  workers 

Telegraph  clerk 

Cigarniaker  

Clerk 

Collector 

Bridge  builder 

Printers. 

General  hotel  and  restaurant  work 

Plumbers 

Ropemaker 

Bakers 

Gardeners 

Steamfitter 


13. 


I 

3 
3 
I 
12 
I 
I 
I 
I 
I 
2 
I 

3 
I 


Musician i 

Putting  in  furnaces  and  ranges. ...  i 

Umbrella  maker  and  repairer i 

Banknote  printer i 

Wood  polisher i 

Painters 2 

Carpenter i 

Unskilled      indoor     and     outdoor 

workers 2 

Varnisher i 

Engineer i 

Coppersmith i 

Stableman i 

Fireman i 

Tinsmith i 

Drivers 3 

Compositor.    i 

Car  driver i 

Stone  cutters 2 

Chance  indoor  workers 3 

Porter i 

Bricklayer i 

Tailors 3 

Iceman i 

Translator i 


129 


Professional,  2  per  cent  ;    commercial,  9  per  cent ;     mechanics,   21  per  cent ; 
trades,  22  per  cent  ;  unskilled,  46  per  cent. 

Average  length  of  time  which  patient  has  not  worked  at  all  before  coming  to 
this  hospital,  2  months,  14  days. 

Average  period  of  unsteady  employment  before  stopping  work  entirely,  3  years, 
4  months. 
Number  of  patients  in  the  condition  of  whose  employment  nothing  unhealth- 

ful  was  revealed 22 

Number  who  have  taken  up  a  poorer  grade  of  work  than  their  main  occupation 

at  time  consumption  appeared  or  after  becoming  ill  with  consumption. . .     27 
Number  who  have  maintained  the  same  grade  of  work  after  becoming  ill  with 

consumption,  but  followed  it  unsteadily 12 

Number  who  were  doing  nothing  at  time  consumption  appeared 3 

Number  who  did  not  work  after  becoming  ill  with  consumption 26 


Commenting  on  these  figures,  Mr.  Easton  says: 
"The  statistics  have  not  made  as  great  a  showing  for  pre- 
vious unhealthy  conditions,  physical,  industrial,  and  social,  as 
I  had  expected.  I  suppose  I  have  been  so  much  impressed 
with  the  stories  of  certain  individuals  that  I  have  not  given 
sufficient  relative  weight  in  my  mind  to  those  of  many  others 
which  have  been  less  tragically  interesting.  Then,  too,  it  must 
be  remembered  that  there  is  nothing  more  individual  than 
suffering  and  failure,  and  that  no  collected  statistics  can  give 
any  adequate  idea  of  the  loss  and  wreck  of  life — in  the  larger 
sense  of  the  word, — of  the  suffering,  conscious  and  unconscious, 
of  the  consumptive  poor.  It  does  not  seem  to  mean  much 
when  it  is  stated  that  twenty-seven  per  cent,  took  up  a  poorer 
grade  of  work  on  becoming  ill,  but  it  certainly  means  a  great 
deal  for  a  commercial  traveller  to  get  down  to  peddling  cheap 
pictures  in  his  old  age ;  or  a  compositor  to  have  to  turn  lamp- 
lighter; or  a  gardener  to  have  to  make  beds  in  a  lodging-house 
as  a  last  resort ;  or  a  skilled  mechanic  to  have  to  take  up  un- 
loading trucks,  or  some  other  rough  work,  and  have  his  former 
associates  'cut'  him  on  account  of  his  industrial  decline,  as 
one  of  them  told  me  was  the  case. ' ' 

The  tabulation  of  the  inquiries  in  regard  to  what  the  patients 
did  for  recreation,  where  they  spent  their  evenings,  and  where 
they  spent  their  Sundays,  was  as  follows : 

130 


Home 

Reading  home , 

Reading-rooms 

Baseball 

Theatre , 

Walkmg 

Club-room 

Visiting , 

Saloon 

Excursions 

(Four  of  them  to  Coney  Island.) 

Church 

Smoking , 

Park 

Mission , 

Fishing , 

Music ■ , 

On  docks 

Cards , 

On  streets 

Pool-room , 

Billiards , 

Y.  M.  C.  A 

Lectures 

Disorderly  houses , 

Dancing 

No  time 

'  Working.         *  Sleeping. 


General 

Recreation 

Evenings 

Sunday 

45 

41 

l8 

13 

II 

14 

6 

2 

2 

I 

23 

7 

2 

20 

16 

17 

7 

3 

3 

7 

5 

7 

41 

41 

19 

12 

9 

5 

5 

3 

2 

2 

2 

2 

2 

I 

I 

I 

I 

I 

I 

3 

7 

2 

5 

5 

I 

I 

I 

I 

I 

2 

2 

'15 

6 

8 

U 

Mr,  Easton's  comments  on  this  table  are: 

"The  information  as  to  recreation,  or  lack  of  recreation,  was 
taken  almost  verbatim  from  the  patients.  For  example,  un- 
doubtedly more  than  forty-five  spent  some  of  their  evenings 
home,  but  only  forty-five  gave  home  in  answer  to  the  question 
where  they  spent  their  evenings.  Home,  of  course,  means 
where  they  slept.  It  might  mean  a  kitchen,  or  a  forecastle,  or 
a  stable,  or  a  lodging-house.  It  will  be  noticed  that  the  nine 
chief  forms  of  recreation,  arranged  in  order  of  their  popularity, 
begin  with  the  saloon  and  end  with  the  church.  The  small 
number  giving  theatre  in  the  evening,  although  it  is  third  in 
popularity,  is  explained  by  the  fact  that  most  of  them  give  it 
under  the  question  on  amusement.  Walking,  reading  and 
visiting  are  relatively  more  popular  in  the  evening  and  on 
Sunday  than  in  general.  This  is  explained  by  the  fact  that 
they  are  usually  given  more  than  once  by  the  same  person, 

131 


while  rank  in  popularity  depends  on  the  number  of  different 
persons  giving  a  certain  amusement.  The  saloon  is  the  most 
popular,  both  by  persons  patronizing  it  and  as  a  way  of  spend- 
ing the  evening  and  Sunday.  The  percentage  for  work  on 
Sunday  is  the  same  as  that  given  by  the  Massachusetts  Bureau 
of  Labor  Statistics  for  that  State." 

The  habits  of  the  lOO  patients  in  regard  to  drink  were  as 

follows: 

Abstainers 2 

Occasional  drinkers ii 

Moderate  drinkers 43 

Hard  drinkers 44 

100 

Among  interesting  personal  items  noted  on  the  history 
schedules  are  the  following : 

No.  66, — Cloak  designer  in  Germany.  Two  and  one-half 
years  in  United  States.  Ill  two  years.  Found  methods  of 
trade  different  in  this  country  and  had  to  take  anything  he 
could  get.  First  waiter  in  good  places,  then  extra  waiter. 
Finally  voice  got  so  weak  he  could  n't  even  get  extra  waiter's 
job.     Well  educated. 

No.  65. —  Restaurant  work  in  damp,  dirty  basement  in 
Bleecker  Street.  Thirty  in  room  where  he  slept,  two  of  them 
consumptives.  Cots  in  two  tiers.  Food  had  no  nourishment 
— weak  soup  and  bread.  The  floor  was  not  scrubbed  the  four 
months  he  was  there.  Place  run  by  religious  charitable  associ- 
ation. Patient  says  they  had  men  working  in  filthy,  damp 
subcellar. 

No.  42. — Has  alternated  iceman  and  kitchenman  for  several 
years,  former  involving  getting  overclothes  wet,  and  latter  all 
kinds  of  bad  conditions. 

No.  43. — Worked  in  bakeries  two  and  one-half  years  after 
becoming  consumptive  .  Worked  with  a  careless  consumptive 
in  one  bakery  for  three  years. 

No.  186. — Three  girls  went  out  with  consumption  from 
laundry  where  he  worked.  One  man  told  me  that  seven  men 
had  left  with  consumption  the  machine  shop  where  he  worked 
the  year  before  becoming  ill. 

132 


No.  105. — Railroad  porter.  Infection  from  consumptive 
travellers  in  sleeping-cars,  going  to  health  resorts.  Same  man 
illustrates  exposure.  Would  stand  on  rear  platform  of  car  to 
cool  off  when  perspiring. 

No.  27. — Covering  furniture  from  house  to  house  for  seven 
months.  Felt  very  weak.  Would  do  a  quarter  of  a  day's 
work  and  then  rest  for  remainder  of  day.  No  treatment  during 
this  time. 

No.  48. — Worked  steadily  at  heavy  work  for  two  months 
after  becoming  ill. 


133 


Appendix  4 

A  LIST  OF  LECTURES  DELIVERED  UN- 
DER THE  AUSPICES  OF  THE  COMMIT- 
TEE ON  THE  PREVENTION  OF  TUBER- 
CULOSIS DURING  THE  WINTER  OF 
1902-3 


135 


A  LIST  OF  LECTURES  DELIVERED  UNDER  THE 
AUSPICES  OF  THE  COMMITTEE  ON  THE  PRE- 
VENTION OF  TUBERCULOSIS  DURING  THE 
WINTER    OF    1902-3 

October  7th. — Jacob  Riis  House,  Henry  St.  Mothers' 
Meeting.     Dr.  Maria  Vinton.     Attendance,  60. 

November  7th. — Nurses'  Settlement,  Henry  St.  Dr.  S.  A. 
Knopf.     Attendance,  18. 

November  loth. — Assembly  Hall,  United  Charities  Building. 
Dr.  J.  H.  Huddleston.     Attendance,  275. 

December  3d.— West  Side  Branch  Y.  M.  C.  A.,  318  West 
57th  St.  Social  Conditions.   Dr.  S.  A.  Knopf.   Attendance,  160. 

December  4th. — Young  Men's  Hebrew  Association,  92d  St. 
and  Lexington  Ave.     Dr.  M.  Fishberg.     Attendance,  120. 

December  8th. — Assembly  Hall,  United  Charities  Building. 
Tuberculosis — Its  Causation  and  Prevention.  Dr.  H.  M.  Biggs. 
Attendance,  no. 

December  loth. — West  Side  Branch  Y.  M.  C.  A.  Predis- 
posing Causes.     Dr.  E.  Le  Fevre.     Attendance,  loi. 

December  15th. — Faith  Presbyterian  Church,  359  West  48th 
St.     Dr.  E.  L.  Dow.     Attendance,  60. 

December  17th. — West  Side  Branch  Y.  M.  C.  A.  Relation 
of  Food  and  Drink  to  Tuberculosis.  Dr.  R.  G.  Freeman. 
Attendance,  127. 

December  i8th. — Young  People's  Association  House  of  Fifth 
Ave.  Presbyterian  Church,  East  63d  St.  Dr.  W.  N.  Berkeley. 
Attendance,  60. 

137 


December  21st. — Young  Men's  Hebrew  Association.  Dr. 
S.  A.  Knopf.     Attendance,  250. 

December  28th. — University  Settlement,  West  Side  Branch, 
38  King  St.  Lecture  in  Italian.  Dr.  A,  Stella.  Attendance, 
125. 

December  29th.— West  Side  Y.  M.  C.  A.  Dr.  H.M.  Biggs. 
Attendance,  89. 

January  6th. — Women's  Guild.  Church  of  Holy  Com- 
munion, Sixth  Ave.  and  20th  St.  Dr.  Sarah  R.  Creighton. 
Attendance,  70. 

January  7th. — Colored  Mission,  135  West  30th  St.  Dr.  E. 
L.  Dow.     Attendance,  175. 

January  8th.— Mothers'  Meeting,  17th  St.  M.  E.  Church. 
Dr.  Mary  Willets.     Attendance,  60. 

January  9th. — 23d  St.  Y.  M.  C.  A.  Dr.  Harlow  Brooks. 
Attendance,  150. 

January  9th. — Friendly  Aid  House,  East  34th  St.  Dr. 
Angenette  Parry. 

January  9th. — Colored  Y.  M.  C.  A.,  West  53d  St.  Social 
Phases.     C.  H.  Johnson.     Attendance,  20. 

January  9th. — Madison  Square  Church  House,  Third  Ave. 
and  30th  St.      Dr.  J.  B.  Huber.     Attendance,  130. 

January  loth. — Educational  Alliance,  East  Broadway.  Lec- 
ture in  Yiddish.     Dr.  M.  Fishberg.     Attendance,  450. 

January  loth. — University  Settlement,  Rivington  and  El- 
dridge  Sts.  Lecture  in  Yiddish  at  East  Side  Janitors'  Society. 
Dr.  Max  Girsdansky.     Attendance,  120. 

January  loth. — Young  People's  Association  House,  East 
63d  St.   Men's  Meeting.    Dr.  W.  N.  Berkeley.  Attendance,  35. 

January  13th. — Girls'  Club,  17th  St.  M.  E.  Church.  Dr.  A. 
S.  Daniell.     Attendance,  8. 

January  i6th.— Colored  Y.  M.  C.  A.  Dr.  E.  L.  Dow. 
Attendance,  30. 

January  i6th. — Union  Settlement,  East  104th  St.  Dr.  W. 
N.  Berkeley.     Attendance,  40. 

January  i6th.— Institute  Hall,  218  East  io6th  St.  Dr.  W. 
C.  Phillips.     (Board  of  Education  Lecture.) 

138 


January  20th. — New  York  Trade  School,  First  Ave.  and 
67th  St.      Dr.  J.  B.  Ruber.     Attendance,  67. 

January  20th. — Public  School  61,  169th  St.  and  Third  Ave. 
Dr.  A.  W.  Baird.     Attendance,  83. 

January  20th. — College  Settlement,  Rivington  St,  Mothers' 
Meeting.     Dr.  Angenette  Parry.     Attendance,  42. 

January  23d.— Colored  Y.  M.  C.  A.,  West  53d  St.  Dr. 
Kilmer.     Attendance,  45. 

January  23d. — Italian  Mothers'  Meeting,  Five  Points  Mis- 
sion.    Dr.  Augusta  Vedin.     Attendance,  56. 

January  26th. — Faith  Presbyterian  Church,  West  48th  St. 
Dr.  R.  G.  Freeman.     Attendance,  96. 

January  27th. — Institute  Hall,  Jay  St.,  Brooklyn.  Dr.  F. 
S.  Kennedy.  (Board  of  Education  Lecture.)  Attendance, 
318. 

January  29th. —  German  Baptist.  Church,  East  ii8th  St. 
German  Lecture.     Dr.  N.  Stadtmuller.     Attendance,  200. 

January  29th. —  Pro-Cathedral,  Stanton  St.  Dr.  H.  P. 
Loomis.     Attendance,  95. 

January  29th. — Boys'  Club,  Amsterdam  Ave.  and  iioth  St. 
C.  H.  Johnson.     Attendance,  63. 

January  29th. — Moravian  Church  (West  Indian  negroes), 
224  West  63d  St.     Dr.  J.  B.  Huber.     Attendance,  20. 

January  29th. — Madison  Square  Church  House,  Third  Ave, 
and  30th  St.  Mothers'  Meeting.  Dr.  A.  Parry,  Attendance, 
28. 

January  30th.— Colored  Y.  M.  C.  A.,  West  53d  St.  Dr. 
A.  W.  Baird.     Attendance,  48. 

February  5th. — King's  Daughters'  House,  East  128th  St. 
Mothers'  Meeting.     Dr.  Jane  Robbins.     Attendance,  50. 

February  6th. — Friendly  Aid  House,  East  34th  St.,  Mothers' 
Meeting.     Dr.  A.  Parry.     Attendance,  25. 

February  7th. — University  Settlement,  Eldridge  St.  Jani- 
tors' Society.  Yiddish  Lecture.  Dr.  Fanny  Dembo.  At- 
tendance, 98. 

February  8th.— Greenwich  House,  26  Jones  St.  Italian 
Lecture.     Dr.  A,  Stella.     Attendance,  24. 

139 


February  9th. — Assembly  Hall,  United  Charities  Building. 
Dr.  S.  A.  Knopf.     Attendance,  48. 

February  loth. — Public  School  47  (Borough  of  Queens). 
Dr.  F.  S.  Kennedy.  (Board  of  Education  Lecture.)  Attend- 
ance, 96. 

February  loth. — 17th  St.  M.  E.  Church.  Girls'  Club.  Dr. 
Reed.     Attendance,  14. 

February  nth. — East  Side  High  School,  East  76th  St.  Dr. 
J.  B.  Huber.  (Board  of  Education  Lecture.)  Attendance, 
114. 

February  nth. — Public  School  131,  Brooklyn.  Dr.  W.  C. 
Phillips.     (Board  of  Education  Lecture.) 

February  12th. — Public  School  82,  70th  St.  and  First  Ave. 
Dr.  W.  C.  Phillips.     (Board  of  Education  Lecture.) 

February  12th. — Public  School  14  (Borough  of  Queens), 
Dr.  F.  S.  Kennedy.     (Board  of  Education  Lecture.) 

February  13th. — Church  of  the  Holy  Communion,  Sixth 
Ave.  and  20th  St.  Dr.  W.  C.  Phillips.  (Board  of  Education 
Lecture.) 

February  14th. — French  Y.  M.  C.  A.,  West  24th  St.  French 
Lecture.     Dr.  S.  A.  Knopf.     Attendance,  95. 

February  19th. — Young  Men's  Club,  47  Greenwich  Ave. 
Dr.  A.  W.  Baird.     Attendance,  40. 

February  22d. — Zion  Educational  League,  Rivington  St. 
Yiddish  Lecture.     Dr.  L.  W.  Zwisohn.     Attendance,  100. 

February  24th. — People's  Union,  East  14th  St.  Dr.  J.  B. 
Huber.     Attendance,  145. 

February  25th. — Teachers  College,  Columbia  University. 
Dr.  S.  A.  Knopf.     Attendance,  100. 

February  26th.— 7th  St.  M.  E.  Church.    Dr.  H.  G.  Watson. 

February  27th. — West  Side  Neighborhood  House,  West 
50th  St.  Dr.  A.  W.  Baird.  (Board  of  Education  Lecture.) 
Attendance,  170. 

February  27th. — Second  Ave.  Branch  Y.  M.  C.  A.  Dr. 
S.  A.  Knopf.     Attendance,  68. 

February  27th. — Deaconess  Training  School,  n86  Madison 
Ave.     C.  H.  Johnson.     Attendance,  36. 

140 


March  ist. — Italian  Church,  East  i  I2th  St.      Italian  Lecture. 
Dr.  A.  Stella.      Attendance,  300. 

March  2d. — Deaconess  Training  School.  Dr.  R.  G.  Free- 
man.    Attendance,  36. 

March  6th. — Nurses'  Settlement,  Henry  St.  Miss  Brandt. 
Attendance,  18. 

March  7th. —  Deaconess  Training  School.  Dr.  Sarah  R. 
Creighton.      Attendance,  40. 

March  9th. — St.  Augustine's  Church,  East  Houston  St. 
Dr.  J.  B.  Huber.     Attendance,  75. 

March  loth.— Public  School  32.  Dr.  J.  B.  Huber.  (Board 
of  Education  Lecture.)     Attendance,  170. 

March  loth. — 'Visitation  Hall  (Borough  of  Brooklyn),  Dr. 
F.  S.  Kennedy.     Attendance,  248. 

March  nth. — Public  School  16  (Borough  of  Richmond). 
Dr.  W.  C.  Phillips. 

March  nth.— Public  School  84,  West  50th  St.  Dr.  A.  W. 
Baird.     (Board  of  Education  Lecture.)     Attendance,  ni. 

March  i6th. — Assembly  Hall,  United  Charities  Building. 
Dr.  A.  Jacobi.     Attendance,  127, 

March  19th. — Public  School  170,  West  63d  St.  Dr.  W.  C. 
Phillips.     (Board  of  Education  Lecture.) 

March  19th. — Deaconess  Training  School.  Dr.  J.  B.  Huber. 
Attendance,  40. 

March  20th. — Parents'  Meeting.  Public  School  80,  West 
41st  St.     Dr.  E.  L.  Dow.     Attendance,  270. 

March  22d. — Young  People's  Association  House,  East  63d 
St.     C.  H.  Johnson.     Attendance,  24. 

March  23d. — Public  School  n  (Borough  of  Queens).  Dr. 
F.  S.  Kennedy.     Attendance,  129. 

March  25th.— Cercle  Coligny.  French  Church,  East  26th 
St.  French  Lecture.  Dr.  C.  S.  Valadier.  Attendance, 
85. 

March  26th. — House  of  Refuge,  Randall's  Island.  Dr.  J. 
B.  Huber.     Attendance,  700. 

March  26th. — King's  Daughters'  Circle  (Colored).  Moravian 
Church,  West  63d  St.      Dr.  A.  S.  Daniell.     Attendance,  18. 

141 


March  27th. — Public  School  72  (Borough  of  Queens).  Dr. 
A.  W.  Baird.     (Board  of  Education  Lecture.) 

March  29th. — Janitors'  Society  Club  Rooms,  Attorney  St. 
Yiddish  Lecture.     Dr.  Paul  Kaplen.     Attendance,  46. 

March  29th. — Public  School  No.  7.  Yiddish  Lecture.  Dr. 
M.  Girsdansky.     Attendance,  239. 

April  3d. — Children's  Aid  Society  House,  224  East  63d  St. 
Dr.  A.  W.  Baird. 

April  6th.— Public  School  166.  Dr.  W.  C.  Phillips.  (Board 
of  Educatiorir  Lecture.) 

April  9th. — St.  Michael's  Parish  House,  99th  St.  and  Amster- 
dam Ave.     Dr.  A.  W.  Baird.     Attendance,  108. 

April  9th. — Public  School  116  (Borough  of  Brooklyn).  Dr. 
F.  S.  Kennedy.     Attendance,  325. 

April  9th. — Public  School  5  (Borough  of  Brooklyn).  Dr. 
W.  C.  Phillips.     (Board  of  Education  Lecture.) 

April  nth. —  Public  School  i,  Catherine  and  Henry  Sts. 
Dr.  A.  W.  Baird.     (Board  of  Education  Lecture.) 

April  13th. —  Assembly  Hall,  United  Charities  Building. 
Dr.  H.  P.  Loomis. 

April  24th. ^ — Public  School  55  (Borough  of  Brooklyn).  Dr. 
F.  S.  Kennedy.     Attendance,  253. 

May  28th.— West  Side  Settlement  House  (Y.  M.  C.  A.),  460 
West  44th  St.     Dr.  Addison  W.  Baird. 


142 


Appendix  5 
THE  GERMS  OF  CONSUMPTION 

By  J.   H.   HUDDLESTON,   M.D. 


143 


THE   GERMS   OF   CONSUMPTION 

What  are  the  Germs  ?— 'Ever  since  1882  the  word  "germ" 
used  in  this  title  has  meant  a  very  definite  thing, — a  vegetable, 
not  a  bug  or  anything  else  belonging  to  the  animal  world, ^ — -but 
a  vegetable  of  a  low  order, — and  so  small  that  a  single  one  can 
be  seen  only  with  a  powerful  microscope.  The  German  phy- 
sician. Dr.  Robert  Koch,  discovered  it  and  proved  that  it  was 
the  one  essential  cause  of  the  disease,  which  in  all  its  forms  is 
known  as  tuberculosis,  and  which  in  some  of  its  forms  is  popu- 
larly known  as  consumption. 

The  germ  is  shaped  like  a  slender,  straight,  or  slightly 
curved  rod,  and  is  so  short  that  it  would  take  three  thousand 
of  them  in  line  to  equal  one  inch  in  length.  It  has  other 
names ;  it  is  sometimes  called  a  microbe,  sometimes  a  bac- 
terium, and  again  a  bacillus.  It  is  alive — that  is,  it  grows  and 
multiplies,  but  it  cannot  move  itself.  So  light  is  it,  however, 
that  it  may  be  carried  in  the  saliva  expelled  in  talking,  or  in 
the  sputum  raised  in  coughing,  and  when  that  saliva  or  sputum 
is  dried  to  dust  it  may  be  blown  about  in  the  dust.  It  may 
live  many  months,  especially  in  a  dark  damp  place,  but  it  is 
usually  killed  by  ordinary  daylight  within  one  week,  and  by 
direct  sunlight  it  is  killed  within  a  few  hours.  Cold  has  no 
effect  on  it,  but  it  is  immediately  killed  by  being  boiled,  and  is 
even  destroyed  by  a  temperature  of  140°  F.  continued  for  fifteen 
minutes.  Many  substances  too,  known  as  disinfectants,  kill 
these  germs  in  a  shorter  or  longer  time — minutes  or  hours. 
Rarely,  if  ever,  does  the  germ  multiply  outside  of  the  body 
except  under  laboratory  conditions — that  is,  when  it  is  planted 

145 


on  a  special  soil,  and  cared  for  at  a  special  temperature,  as'may 
be  done  in  a  laboratory. 

Where  are  they  Found? — They  are  found  in  every  person  or 
animal  affected  with  tuberculosis,  in  the  parts  of  the  body  so 
affected.  Almost  every  tissue  may  be  the  seat  of  growth  of 
this  parasite,  but  most  frequently  by  far  the  lungs  are  affected, 
though  in  children  what  are  called  the  lymph  glands  and  the 
bones  are  especially  attacked.  Millions  of  germs  may  exist  in 
a  single  organ.  They  are  also  found,  and  in  this  is  the  danger, 
wherever  the  sputum  from  a  lung  so  diseased  has  fallen,  or 
wherever  that  dried  sputum  has  been  blown.  They  are  also 
often  found  in  the  milk  from  a  diseased  cow,  or  in  the  flesh 
from  a  diseased  animal, — or  in  the  laboratory  on  the  special 
soil  on  which  they  are  grown.  In  the  laboratory  so  many 
may  be  growing  together  in  a  glass  that  they  can  be  seen  as  a 
grayish-white  mass. 

WJiat  do  they  Do  ? — If  some  are  floating  in  the  air  as  they 
are  apt  to  do  wherever  dust  in  an  infected  place  is  stirred  up, 
and  one,  two,  or  more  pass  into  the  nose  or  mouth  with  the 
air  breathed  in,  and  if  they  obtain  lodgment  in  some  tissue, 
and  finding  the  necessary  food  and  temperature  there  begin 
to  grow  just  as  a  fungus  does  on  another  plant,  —  what  hap- 
pens? In  the  first  place,  just  as  dust  getting  into  the  eye 
irritates  it  and  makes  it  water — that  is,  makes  the  eye  react, — 
so  these  germs  irritate  the  tissue  and  set  up  a  reaction  there, 
and  on  the  character  of  this  reaction  depends  the  fate  of  the 
person  or  animal  so  infected.  In  every  case,  some  of  the  cells 
of  the  body  gather  round  the  germs,  and  form  a  little  mass  or 
lump  there,  which  is  called  a  tubercle,  and  these  tubercles  vary 
in  size  from  the  minutest  pin-point  to  the  size  of  a  marble  or 
larger,  and  if  many  fuse  together  they  may  attain  almost  any 
size  capable  of  being  contained  in  the  organ.  Now  around 
these  tubercles  there  may  take  place  a  process  ending  in  heal- 
ing, or  one  ending  in  destruction  and  death.  Just  as  a  wound 
heals  with  the  formation  of  a  dense,  hard  scar,  so  scar  material 
may  be  formed  around  and  through  the  tubercles,  shutting 
them  in,  and  this  scar  may  even  be  turned  into  stone.     When 

146 


there  is  a  firm  enough  scar  formed,  the  germs  can  do  no  injury, 
and  the  person  is  said  to  be  cured.  Again  the  irritation  may 
be  so  great  that  the  tissue  becomes  inflamed  for  some  distance 
around  the  germs ;  if,  for  example,  the  germs  are  in  the  lung, 
a  part  of  the  lung  may  become  solid  just  as  it  does  in  pneu- 
monia. While  the  germs  are  multiplying  they  form  a  poison 
which  is  itself  an  irritant,  and  which,  being  absorbed,  causes 
the  fever  and  certain  other  of  the  symptoms  of  tuberculosis. 
When  these  tubercles  and  tubercular  masses  attain  some  size 
they  usually  die  at  their  centres,  and  if  there  is  an  opportunity, 
as  when  there  is  an  air  tube  leading  from  them  to  the  open  air, 
this  dead  matter  may  be  coughed  up,  forming  part  of  the 
sputum  of  consumptives. 

No  dust  causes  consumption  unless  it  contains  this  particular 
germ,  but  wherever  a  consumptive  has  not  been  careful  of  his 
sputum,  and  has  allowed  it  to  mingle  with  the  dust,  that  dust 
has  become  infectious.  There  are  many  sorts  of  germs  in  all 
ordinary  dust  besides  the  germs  of  consumption,  and  some  of 
these  other  germs,  when  breathed  in,  may  grow  in  this  same 
dead  tubercular  matter,  make  it  break  down  faster,  and  help  in 
blood  poisoning.  It  is  therefore  one  of  the  benefits  of  pure 
air  that  the  person  breathing  it  does  not  have  to  fight  these 
other  germs.  When  this  dead  matter  is  coughed  out,  a  hole  is 
left  behind,  and  the  cavities  in  the  lungs  which  many  con- 
sumptives have  are  thus  begun.  This  dead  matter  regularly 
contains  the  germs  of  consumption,  sometimes  in  very  large 
numbers.  The  actual  number  in  a  measured  amount  has  been 
counted  in  some  cases  under  a  microscope,  and  by  this  count, 
with  a  knowledge  of  the  amount  of  sputum  the  consumptive 
has  raised,  it 'has  been  proved  that  as  many  as  four  thousand 
million  germs  have  been  expectorated  in  twenty-four  hours. 

While  the  tubercles  are  increasing  in  size,  some  of  the  germs 
may  get  into  a  blood-vessel,  and  be  carried  off  with  the  blood 
and  deposited  in  another  organ.  One  or  more  organs  at  a  dis- 
tance may  thus  be  infected,  and  if  the  number  of  germs  so 
scattered  is  large  there  may  be  tubercles  found  all  over  the 
body — a  rapidly  fatal  condition. 

147 


How  do  they  Ente7'  the  Body  ? — It  is  possible  for  the  germs 
of  tuberculosis  to  get  into  the  body  in  several  distinct  ways; 
first  they  may  be  swallowed  in  food  as  in  tuberculous  milk  or 
meat  or  in  the  milk  taken  by  an  infant  from  the  unclean  nipple 
of  a  consumptive  mother. 

Unless  the  greatest  cleanliness  is  habitual,  the  hands  of  a 
consumptive  are  often  contaminated  with  saliva  or  sputum, 
and  infect  food,  books,  papers,  and  other  things;  when  these 
infected  articles  are  handled  by  others,  some  of  the  germs  on 
them  may  be  carried  to  the  mouth  and  swallowed.  The  mous- 
tache and  beard  of  a  consumptive  can  be  kept  clear  of  germs 
only  by  constant  care,  and  if  they  are  not  clean  they  may  infect 
napkins  and  handkerchiefs.  Kissing  a  consumptive  may  also 
permit  the  germs  to  be  transferred  to  another.  When  the 
germs  are  taken  into  the  mouth  they  may  be  swallowed  and 
pass  through  the  entire  digestive  tract  and  be  evacuated  with- 
out doing  harm,  or,  on  the  other  hand,  they  may  come  to  rest 
and  cause  infection  at  any  point  in  the  tract — though  oftenest 
in  the  tonsils  and  in  the  intestines. 

In  the  second  place,  and  more  rarely,  germs  enter  through 
cuts  in  the  skin  when  one  is  handling  tuberculous  material, 
like  the  handkerchief  or  sputum  jar  of  a  consumptive;  and 
third,  most  rarely  of  all,  they  may  be  given  to  the  unborn 
child  by  the  mother. 

Practically,  however,  these  germs  in  the  majority  of  cases 
enter  in  the  fourth  way,  as  infected  dust  breathed  in  by  the 
person.  In  this  case  they  may  infect  first  the  larynx,  or  voice 
box,  or  the  large  or  small  air  tubes,  or  the  lungs  themselves. 
In  every  city,  and  New  York  is  no  exception,  there  is  a  large 
number  of  careless  consumptives,  who  allow  their  undisinfected 
sputum  to  mingle  with  the  dust  wherever  they  are.  These 
people  are  dangerous  ;  careful  consumptives  are  not  dangerous, 
but  the  careless  ones  infect  their  surroundings  indoors  and  on 
the  streets. 

What  Protects  against  Inhaled  Dust  ? — Inasmuch  as  Dr. 
Prudden  has  shown  that  a  person  living  in  New  York  City 
breathes  into  his  lungs  in  the  course  of  a  minute  a  number  of 

148 


bacteria,  varying  from  ten  to  four  hundred  according  to  the 
place  where  he  is,  it  is  worth  while  to  consider  what  protection 
he  has  against  these.  Some  of  them,  it  should  be  said,  are 
harmless;  others  might  cause  disease,  and  in  the  number  there 
may  be  some  of  the  germs  of  consumption. 

There  are,  roughly  speaking,  four  lines  of  defense.  In  the 
first  place,  a  great  many  bacteria  are  caught  in  the  nose  or 
throat  by  the  mucus,  and  are  blown  out  or  spat  out  or  swal- 
lowed. These,  therefore,  do  not  enter  the  lungs.  In  the  next 
place,  the  material,  which  starts  down  into  the  lungs  along  the 
windpipe  and  smaller  air-tubes,  and  comes  to  rest  on  the  walls 
of  the  tubes,  is  swept  out  by  the  very  minute  projecting  hairs 
called  cilia,  which  line  the  walls,  and  constantly  move  in  such 
a  manner  that  whatever  is  on  them  is  driven  away  from  the 
lungs  up  to  the  outer  air. 

There  is  a  third  protection  in  the  existence  in  the  body  of 
certain  cells  which  travel  about  and  gather  up  waste  material 
and  carry  it  off  to  deposit  it  in  a  safe  place  or  to  digest  and 
destroy  it.  Some  of  these  cells  imprison  the  germs  and  carry 
them  away  in  the  same  way.  Finally,  if  some  of  the  germs  do 
get  into  the  smallest  air  spaces  of  the  lungs  and  pass  through 
their  walls,  they  are  taken  up  by  a  nutrient  fluid  called  the 
lymph,  which  circulates  all  through  the  body,  and  carried  to 
the  fourth  defense — certain  glands  which  are  placed  at  the 
roots  of  the  lungs  as  well  as  at  other  points  in  the  body,  and 
which  act  as  filters.  By  these  the  germs  are  caught  out  of  the 
stream  and  prevented  from  going  to  the  rest  of  the  body. 


149 


Appendix  6. 

TUBERCULOSIS— ITS  CAUSATION 
AND  PREVENTION 

By  HERMANN  M.  BIGGS,   M.D. 

MEDICAL  OFFICER  AND  DIRECTOR  OF  THE  BACTERIOLOGICAL  LABORA- 
TORIES,  DEPARTMENT  OF  HEALTH,   NEW  YORK  CITY 
PROFESSOR  OF  CLINICAL  MEDICINE,   UNIVERSITY  AND  BELLEVUE 
MEDICAL    COLLEGE 


151 


TUBERCULOSIS— ITS   CAUSATION   AND 
PREVENTION 

No  subject  more  vitally  concerns  the  welfare  of  a  community 
than  that  pertaining  to  its  healthfulness.  How  its  members 
live,  and  how  and  at  what  age  they  die,  how  much  sickness 
occurs  among  them  and  what  is  its  nature,  are  questions  of 
vital  importance,  both  to  the  community  as  a  whole  and  to 
each  individual  in  it.  These  are  essential  features  of  the 
problem,  whose  gradual  solution  will  teach  men  more  and 
more  how  to  live  properly,  and  how  they  may  secure  longer, 
healthier,  and  therefore  happier  lives. 

The  healthfulness  of  any  community  or  locality  is  to  be 
judged  by  the  statistics  of  sickness  and  death,  considered  in 
relation  to  the  causes  of  such  sickness  and  death  (it  is  not  only 
the  number  of  deaths  or  the  number  of  cases  of  sickness  in 
proportion  to  the  population,  but  also  the  nature  of  the  dis- 
eases which  cause  this).  In  rural  districts  the  degree  of  health- 
fulness depends  largely  on  the  natural  conditions,  such  as 
elevation,  climate,  soil,  and  to  a  less  extent  upon  artificial 
conditions.  In  densely  populated  cities,  on  the  contrary,  the 
natural  conditions  become  relatively  unimportant  factors  in 
determining  the  degree  of  healthfulness,  so  much  do  they  be- 
come subordinated  to  the  artificiar conditions  resulting  from 
the  lives  and  labor  of  the  inhabitants.  It  may  be  said,  within 
certain  limitations,  that  the  inhabitants  of  every  city  have  it 
largely  within  their  power  to  determine  what  the  death-rate  of 
their  city  shall  be.  The  presence  of  much  sickness  and  of  a 
high  death-rate  in  any  urban  population  are  largely  due  to  the 

153 


existence  of  unsanitary  conditions  in  the  occupations,  habita- 
tions, food,  and  water  supply  of  the  inhabitants — all  factors 
which  lie  to  a  great  extent  within  their  control.  Hence  when 
any  city  has  a  high  death-rate— for  example,  when  thirty  or 
thirty-five  persons  out  of  every  thousand  of  the  population  die 
each  year,  as  was  formerly  the  case  in  Liverpool  and  New 
York,  instead  of  fifteen  or  twenty,  as  is  the  case  in  many  of 
the  larger  cities  to-day — it  is  because  unsanitary  conditions  are 
permitted  to  exist.  These  exist  to  a  very  small  extent  from 
necessity,  but  chiefly  because  of  ignorance,  neglect,  and  in- 
difference on  the  part  of  the  people,  or  incompetence  on  the 
part  of  the  authorities. 

The  average  length  of  life  in  any  country  or  city  is  spoken 
of  as  the  "expectation  of  life  at  birth."  This  average  life-term 
in  some  cities— for  instance  in  Liverpool  and  Manchester, 
which  have  been  distinguished  for  their  high  death-rates — is 
often  but  little  more  than  one-half  that  of  the  healthiest 
country  district.  The  average  lifetime  of  each  person  born  in 
Liverpool,  until  recently,  was  twenty-six  years ;  in  London  it 
was  thirty-seven  years ;  while  in  Surrey,  a  healthy  district,  it 
was  forty-six  years. 

These  considerations  show  how  vast  is  the  significance  to 
every  individual  of  the  degree  of  healthfulness  of  the  com- 
munity, for  upon  it  depends  not  only  his  or  her  relative  free- 
dom from  illness,  but  also  his  or  her  probable  lifetime. 

In  the  casual  consideration  of  the  healthfulness  of  communi- 
ties as  compared  with  the  conditions  existing  in  earlier  cen- 
turies, we  are  inclined  to  think  without  investigation  that 
there  has  been  but  little  advance  in  modern  times,  and  that 
while  some  diseases  have  been  greatly  restricted,  or  entirely 
stamped  out,  these  have  been  replaced  by  others  equally  as 
fatal  to  the  human  race.  More  careful  study,  however,  shows 
how  erroneous  are  these  views.  In  the  seventeenth  and  eigh- 
teenth centuries,  the  average  annual  death-rate  per  looo  of  the 
population  throughout  the  civilized  world  was  at  least  50,  and 
probably  much  more.  From  1620  to  1643,  the  absolute  annual 
mortality  for  London  was  over  70  per  1000  of  the  population, 

154 


and  the  average  duration  of  life  of  each  person  born,  less  than 
15  years.  One  hundred  and  fifty  years  later,  for  the  decennial 
period  ending  in  1780,  the  expectation  of  life  (or  the  average 
lifetime)  in  London  had  increased  only  4  years,  and  was  19 
years;  while  from  1831  to  1835,  including  an  epidemic  year, 
the  death-rate  had  fallen  to  32  per  1000,  and  the  mean  expec- 
tation of  life  had  increased  from  19  years  to  nearly  30  years. 
At  the  present  time  the  mean  life-term  for  all  England  is  con- 
siderably more  than  40  years,  or  more  than  double  that  of 
1780.  From  1770  to  1780,  in  London,  not  less  than  5  in  1000 
died  annually  of  small-pox ;  the  death-rate  from  this  disease  is 
now  an  insignificant  fraction.  In  the  sixteenth  century,  fever, 
plague,  cholera,  and  dysentery — diseases  which  are  now  practi- 
cally extinct  in  civilized  communities  —  destroyed  annually 
nearly  31  out  of  every  looo  of  the  inhabitants  of  London,  or 
nearly  twice  the  total  deaths  now  from  all  causes.  Even  pre- 
vious to  1875,  518  out  of  every  looo  children  born  in  Liverpool 
died  during  the  first  ten  years  of  life,  while  in  the  healthy  dis- 
tricts of  England  only  205  died  during  this  period.  Formerly 
in  New  York  City  more  than  600  out  of  every  1000  children 
died  ^uring  the  first  ten  years  of  life;  this  mortality  has  now 
been  reduced  one-half. 

I  have  referred  to  these  general  facts  in  regard  to  the  signifi- 
cance of  death-rates,  and  to  certain  features  in  the  sanitary 
history  of  the  past,  simply  to  emphasize  the  importance  to  the 
individual  of  the  sanitary  conditions  of  the  locality  in  which 
he  lives,  and  to  bring  out  more  clearly  the  enormous  advances 
that  have  taken  place  in  the  last  fifty  years  in  general  sanitary 
conditions.  A  large  number  of  those  diseases  which  in  the 
past  frequently  decimated  the  population  have  been  either 
restricted  within  narrow  limits  or  completely  stamped  out. 
Plague,  typhus  fever,  Asiatic  cholera,  leprosy,  and  small-pox 
are  among  the  diseases  which  either  have  been  completely 
stamped  out  in  civilized  communities,  or  occur  only  spasmodi- 
cally or  in  small  epidemics ;  their  influence  in  the  production 
of  sickness  and  death  has  fallen  to  insignificant  proportions. 
The  prevalence  of  typhoid  fever  in  most  well-regulated  com- 

155 


munities  has  very  greatly  decreased.  Through  the  introduc- 
tion of  diphtheria  anti-toxin,  the  mortality  from  diphtheria  has 
been  reduced  to  one-half,  one-third,  or  to  even  one-fourth 
in  some  localities,  of  what  it  formerly  was.  Through  the  re- 
markable observations  made  in  Cuba  by  Ross  of  the  United 
States  Army,  and  his  associates,  the  prevalence  of  yellow  fever 
is  likely  to  be  restricted  in  the  future  within  narrow  limits,  as 
has  been  previously  the  case  with  each  of  the  other  great  epi- 
demic diseases. 

I  might  mention  several  other  infectious  diseases  whose 
prevalence  has  been  restricted  within  very  much  narrower 
lines  through  the  developments  in  modern  preventive  medi- 
cine, and  among  these  is  tuberculosis ;  and  still  there  is  no 
problem  which  confronts  the  sanitary  authorities  of  the  large 
municipalities  at  the  present  time  equal  in  its  importance  and 
magnitude,  than  that  presented  by  the  tuberculous  diseases, 
nor  is  there  any  other  sanitary  proposal  which  offers  the 
promise  of  such  vast  returns  in  a  diminishing  rate  of  sickness 
and  death,  as  one  which  provides  successful  measures  for  the 
prevention  of  this  disease.  This,  although  not  a  new  problem, 
is  of  supreme  importance.  The  tuberculous  diseases  are  not 
more  prevalent  than  formerly ;  oft  the  contrary,  there  has  been 
a  steady  and  material  decline  in  the  death-rate  caused  by  them 
in  most  of  the  large  cities  of  the  world ;  but  only  in  recent 
years  have  the  sanitary  authorities  and  the  medical  profession 
begun  to  have  some  realization  of  the  great  possibilities  in  the 
restriction  of  this  disease. 

A  comprehension  of  the  full  significance  of  the  discoveries 
of  Robert  Koch,  made  twenty  years  ago,  on  the  prevention  of 
tuberculosis  has  only  slowly  found  its  way  into  the  minds  of 
the  medical  profession,  and  even  now  a  large  proportion  of  the 
profession  and  of  the  laity  have  failed  to  grasp  its  vast  in- 
fluence on  the  present  and  future  happiness  and  prosperity  of 
the  human  race.  Koch  showed  in  1882  that  tuberculosis  was 
an  infectious  and  communicable  disease,  produced  by  a  germ, 
the  tubercle  bacillus.  It  followed  as  a  necessary  result  from 
his  discoveries,  that  it  was  an  absolutely  preventable  disease. 

156 


So  slowly,  however,  did  the  significance  of  these  discoveries 
penetrate  the  minds  of  the  profession  and  the  people  that 
already  twenty  years  have  passed  and  we  have  only  just  now 
begun  to  organize  inadequate  measures  for  the  prevention  of 
this  disease. 

Statistics,  showing  the  great  prevalence  of  the  tubercular 
diseases,  have  been  quoted  so  frequently  as  to  have  almost 
lost  their  force,  and  still  the  people,  the  legislators,  the  sani- 
tary authorities,  and  even  the  medical  profession,  have  re- 
mained indifferent  to  the  vast  expenditure  unnecessarily  made 
by  the  human  race  to  this  evil.  Only  limited,  ineffectual 
efforts  are  made  in  its  suppression,  and  we  still  view  with  com- 
parative indifference  the  ravages  of  a  disease  which  causes  from 
one-quarter  to  one-third  of  all  the  suffering  and  death  at  the 
best  period  of  life — between  the  ages  of  fifteen  and  fifty-five — 
and  this,  too,  when  the  evidence  at  command  should  be,  it 
seems  to  me,  conclusive  to  every  reasonable  mind  that  this 
loss  could  be  largely  prevented  at  a  comparatively  small  cost 
in  sacrifice,  labor,  and  money.  I  make  this  statement  with  a 
full  realization  of  its  meaning,  and  after  a  familiarity  with  the 
sanitary  problems  involved  gained  by  an  active  participation 
in  their  study  in  a  great  city  for  a  period  of  nearly  fifteen  years. 

It  may  be  useful  to  discuss,  in  as  simple  a  manner  as  possi- 
ble, certain  questions  which  are  suggested  in  regard  to  tuber- 
culosis. First:  What  is  tuberculosis?  The  disease  known  as 
tuberculosis,  and  when  affecting  the  lungs,  as  pulmonary 
tuberculosis  or  consumption,  is  an  infectious  and  communi- 
cable disease.  It  is  very  common  in  human  beings  and  in 
certain  of  the  domestic  animals,  especially  cattle.  About  one- 
fourth  of  all  deaths  occurring  in  human  beings  during  adult 
life  in  all  civilized  countries  is  caused  by  it,  and  nearly  one- 
half  of  the  entire  adult  population  at  some  time  in  life  acquire 
it.  It  has  been  proved  beyond  any  possibility  of  doubt  that 
a  living  germ  called  the  tubercle  bacillus  is  the  cause,  and  the 
only  cause,  of  tuberculosis.  It  does  not  seem  necessary  to 
state  the  facts  upon  which  this  assertion  is  based,  for  the  dis- 
covery first  made  by  Robert  Koch  in  1882  has  been  confirmed 

157 


so  often  and  so  completely  that  it  now  constitutes  one  of  the 
most  absolutely  demonstrated  facts  in  medicine.  Tuberculosis 
may  affect  any  organ  of  the  body,  but  most  frequently  first 
involves  the  lungs,  and  is  then  commonly  known  as  consump- 
tion. When  it  affects  the  skin  it  is  known  as  lupus ;  the  lymph 
glands  are  frequently  diseased  and  especially  those  in  the  neck, 
and  this  type  was  formerly  known  as  scrofula.  The  commoner 
forms  of  chronic  disease  of  the  knee  joint,  hip  joint,  and  spine 
are  generally  the  result  of  tubercular  infection  of  the  joints  and 
bones.  The  disease  may  also  affect  the  throat,  the  intestinal 
canal,  the  coverings  of  the  brain,  or  any  of  the  other  organs 
and  tissues  of  the  body.  It  is  always  the  same  disease  when 
found  in  any  one  of  these  parts,  and  always  produced  by  the 
same  germ — the  tubercle  bacillus.  When  these  germs  find 
their  way  into  the  body  they  multiply  there,  if  favorable  con- 
ditions for  their  growth  exist,  and  produce  small  new  growths 
or  nodules  which  are  called  tubercles,  and  from  these  the  dis- 
ease tuberculosis  derives  its  name.  As  the  result  of  the  action 
of  the  germs  contained  in  the  tubercles  they  tend  to  soften, 
and  the  discharges  from  these  softened  tubercles  containing 
the  living  germs — tubercle  bacilli — are  thrown  off  from  the 
body.  In  pulmonary  tuberculosis,  or  consumption,  these 
germs  are  contained  in  the  expectoration,  often  m  almost  in- 
credible numbers.  It  has  been  estimated  that  in  some  cases 
two  or  three  thousand  million  tubercle  bacilli  are  discharged 
in  the  expectoration  from  a  single  case  of  consumption  in  the 
course  of  twenty-four  hours.  The  germs  thus  thrown  off  do 
not  grow  under  ordinary  conditions  outside  the  living  human 
or  animal  body,  although  they  may  frequently  retain  their 
vitality  and  virulence  for  long  periods  of  time,  even  when 
thoroughly  dried.  As  tuberculosis  only  results  from  the  action 
of  these  germs,  it  follows,  from  what  has  just  been  said,  that 
when  the  disease  is  acquired  it  must  result  from  receiving  into 
the  body  the  living  germs  which  have  come  from  some  other 
living  being  affected  with  the  disease.  It  should  be  especially 
noted  in  this  connection  that  tuberculosis  differs  widely  in  this 
respect  from  some  other  infectious  and  communicable  diseases, 

158 


like  typhoid  fever,  in  which  the  germs  multiply  outside  the 
living  body  after  having  been  thrown  off  in  the  discharges  of 
some  persons  suffering  from  the  disease.  The  tubercle  bacilli 
do  not  find  the  conditions  necessary  for  their  multiplication, 
except  in  living  beings,  human  or  animal,  and  therefore,  when 
tuberculosis  occurs,  it  must  be  as  the  result  of  infection  directly 
by  the  same  identical  tubercle  bacilli,  which  have  been  thrown 
off  from  some  human  being,  or  possibly  from  some  animal, 
suffering  from  the  disease. 

Tuberculosis  is  commonly  produced  in  the  lungs,  which  are 
the  organs  most  frequently  affected  first,  by  breathing  air  in 
which  living  germs  are  suspended,  as  dust.  The  material 
which  is  discharged,  sometimes  in  large  quantities,  by  persons 
suffering  from  consumption,  as  has  been  said,  contains  the 
germs  often  in  enormous  numbers.  This  material,  when  ex- 
pectorated, frequently  lodges  in  places  where  it  afterward 
dries,  as  on  the  street,  floors,  carpets,  clothing,  handkerchiefs. 
After  drying,  it  is  very  apt  in  one  way  or  another  to  become 
pulverized  and  then  floats  in  the  air  as  dust.  It  should  be 
especially  noted  that  it  is  chiefly  a  source  of  danger  after  dry- 
ing, and  not  when  in  a  moist  condition.  It  has  been  shown 
experimentally  that  dust  collected  from  the  most  varied  points 
— in  hospital  wards,  dispensaries,  asylums,  prisons,  rooms  in 
private  houses,  and  even  street  cars,  where  consumptive 
patients  are  present  or  have  been  present — is  capable  of  pro- 
ducing tuberculosis  in  animals  when  used  for  their  inoculation. 
Such  dust  may  retain  for  weeks  its  power  of  producing  the 
disease.  On  the  other  hand,  dust  collected  from  rooms  in  in- 
stitutions or  houses  which  have  not  been  occupied  by  tuber- 
cular patients  does  not  produce  the  disease  when  used  for  the 
inoculation  of  animals.  These  observations  show  conclusively 
that  where  there  are  cases  of  pulmonary  tuberculosis,  under 
ordinary  conditions,  the  dust  surrounding  them  is  likely  to 
contain  the  tubercle  bacilli,  and  persons  inhaling  the  air  in 
which  this  dust  is  suspended  may  be  taking  in  the  living  germs. 
It  should,  however,  be  distinctly  understood  that  the  breath  of 
tuberculous  patients  and  the  moist  sputum  received  in  proper 

159 


cups  are  not  elements  of  danger,  but  only  the  dried  and 
pulverized  sputum.  The  breath  and  moist  sputum  are  free 
from  danger  because  the  germs  are  not  dislodged  from  moist 
surfaces  by  currents  of  air.  Handkerchiefs  and  clothing  which 
have  been  soiled  by  sputum  are  particularly  dangerous  because 
on  these  the  sputum  dries,  scales  off,  and  then  becomes  pulver- 
ized. If  all  discharges  of  tuberculous  persons  were  destroyed 
at  the  time  of  exit  from  the  body,  practically  the  only  danger 
of  communication  of  this  disease  from  man  to  man  would  be 
removed.  It  follows  then  as  an  absolutely  necessary  sequence 
of  what  has  been  said  that  tuberculosis  is  not  only  a  distinctly 
preventable  disease,  but  is  much  more  readily  and  certainly 
preventable  than  most  of  those  diseases  usually  called  con- 
tagious, for  the  sole  source  of  infection  is  contained  in  the 
discharges,  which  may  be  readily  destroyed  at  the  time  of  exit 
from  the  body. 

It  may,  perhaps,  be  well  here  to  define  a  little  more  fully 
what  is  meant  by  an  infectious  and  communicable  disease,  such 
as  tuberculosis  is,  and  how  it  differs  from  one  which  is  con- 
tagious. Any  disease  which  is  produced  by  the  entrance  and 
multiplication  in  the  body  of  some  minute  form  of  animal  or 
vegetable  life  of  simplest  structure  is  called  an  infectious  dis- 
ease. The  contagious  diseases,  examples  of  which  are  small- 
pox, scarlet  fever,  measles,  etc.,  form  one  class  of  the  infectious 
diseases.     They  have  several  distinguishing  characteristics: 

(i)  In  none  of  these  contagious  diseases  have  we  any  know- 
ledge as  to  the  exact  nature  of  the  specific  organism  causing 
them.  This  is  a  rather  remarkable  fact  and  seems  to  indicate 
that  they  are  caused  by  some  kind  of  life  which  our  present 
methods  of  investigation  will  not  reveal. 

(2)  These  diseases  may  be  transmitted  to  well  persons  through 
simple  proximity  to  the  sick  for  a  short  period  of  time;  small- 
pox, for  example,  may  be  contracted  by  passing  in  the  street 
a  person  suffering  with  the  disease.  A  person  sick  with  one  of 
the  contagious  diseases  may  so  infect  the  atmosphere  of  the 
room  in  which  he  is  present  that  any  susceptible  person  enter- 
ing it  may  contract  the  disease. 

160 


(3)  In  the  contagious  diseases,  there  are  no  adequate  pre- 
cautions known  which  will  render  a  person  suffering  from  one 
of  these  diseases  free  of  danger  to  those  coming  in  immediate 
contact  with  him. 

The  class  of  infectious  diseases  to  which  tuberculosis  belongs, 
I  have  called  communicable  and  non-contagious.  In  this  class 
belong  typhoid  fever,  diphtheria,  Asiatic  cholera,  pneumonia, 
tuberculosis,  etc.  In  each  of  these  diseases,  the  cause  is  well- 
known,  and  its  life  history  has  been  thoroughly  studied.  We 
know  how  the  germs  enter  the  body,  what  they  do  in  the  body, 
how  they  are  thrown  out  of  the  body,  and  how  they  act  out- 
side of  the  body.  They  are  always  contained  in  some  dis- 
charges from  the  body:  viz.,  in  typhoid  fever,  in  the  discharges 
from  the  bowels  and  kidneys ;  in  cholera,  in  the  discharges  from 
the  intestines  or  stomach ;  in  tuberculosis,  in  discharges  from 
the  diseased  tissues  wherever  they  may  be.  If  these  discharges 
are  destroyed  at  the  time  of  their  exit  from  the  body,  all  danger 
of  communication  of  the  disease  to  others  is  removed.  The 
room  occupied  by  a  person  ill  from  one  of  these  diseases  and 
the  atmosphere  of  it  are  not,  under  proper  conditions,  in  any 
way  a  source  of  danger.  The  most  intimate  contact  with  a 
tuberculous  patient  may,  under  proper  conditions,  be  quite 
free  of  danger.  It  has  been  frequently  said  that  a  properly 
conducted  sanatorium  for  consumptives  is  the  safest  place  one 
can  find,  so  far  as  the  liability  of  contracting  this  disease  is 
concerned. 

I  have  always  felt  that  much  harm  has  been  done  by  calling 
tuberculosis  a  contagious  disease.  It  causes  confusion  in  the 
lay  mind,  because  the  popular  conception  of  a  contagious 
disease  is  connected  with  such  diseases  as  scarlet  fever  and 
small-pox,  in  which  a  very  limited  contact  may  result  in  in- 
fection. Every  person  should  understand  that  tuberculosis'  is 
quite  different  in  nature  from  these  diseases,  and  the  mental 
confusion  caused  by  calling  it  contagious,  often  results  in  pro- 
ducing incredulity,  or  a  totally  unwarranted  fear  of  contact 
with  tuberculous  persons.  Too  much  emphasis  cannot  be 
placed  on  the  fact  that  consumptives  are  only  a  source  of 

161 


danger  through  the  discharges  from  the  diseased  tissue  — 
chiefly  the  sputum — and  if  these  are  destroyed  the  most  inti- 
mate contact  with  tuberculous  patients  is  free  of  danger. 

It  is  a  well-known  fact  that  some  persons,  especially  the 
members  of  certain  families,  are  particularly  liable  to  tubercu- 
losis, and  that  this  liability  may  be  transmitted  from  the  parents 
to  the  children ;  so  marked  is  this  liability  and  so  frequent  is 
the  development  of  the  disease  in  families  in  different  genera- 
tions that  the  affection  was  long  considered  hereditary.  We 
now  know  that  tuberculosis  can  only  be  caused  by  the  entrance 
of  the  tubercle  bacilli  into  the  body  and  their  growth  in  the 
body,  and  this  inherited  liability  simply  renders  the  individual 
a  more  easy  prey  to  the  germs  when  once  they  have  gained 
entrance.  The  varying  susceptibility  to  tuberculosis  found 
in  different  families  and  in  different  individuals  is  perfectly 
analogous  to  that  existing  with  relation  to  other  diseases,  only 
that  in  the  case  of  tuberculosis  the  susceptibility  is  more  gen- 
eral under  the  natural  conditions  of  exposure  to  infection  than 
is  the  case  with  almost  any  other  disease.  It  has  been  argued 
that  if  tuberculosis  is  so  widely  disseminated  as  is  claimed,  and 
so  many  tubercle  bacilli  are  discharged  by  affected  individuals, 
every  individual,  especially  in  large  cities,  must  from  time  to 
time  be  exposed  to  infection,  and  that  consequently,  if  these 
facts  were  true  as  claimed,  all  persons  would  sooner  or  later 
contract  the  disease.  In  reply  to  this,  it  may  be  said  that  the 
observations  of  those  with  the  largest  experience  in  performing 
autopsies  show  that  nearly  one-half  of  all  adults  living  in  large 
cities  do  at  some  time  contract  the  disease,  and  it  has  been  said 
that  in  the  Vienna  General  Hospital,  which  is  the  largest  gen- 
eral hospital  in  the  world,  in  fully  eighty-five  per  cent,  of  dead 
bodies  some  tubercular  changes  are  found,  and  in  nearly  forty- 
five  per  cent,  of  all  the  deaths  occurring  in  this  hospital  tuber- 
culosis is  the  cause.  The  reason  that  a  still  larger  percentage 
of  the  human  race  do  not  contract  the  disease  or  die  of  it  is 
because  they  have  sufficient  resistance  to  overcome  and  destroy 
the  tubercle  bacilli  which  they  take  in.  As  it  is,  on  the  average 
about  one-third  of  the  deaths  between  the  ages  of  fifteen  and 

162 


forty-five  are  caused  by  this  disease,  and  probably  in  one- 
quarter  more  of  the  deaths  occurring  in  persons  over  fifteen 
years  of  age  some  tubercular  changes  will  be  found  in  the  body. 
This  resistance  to  tubercular  infection,  which  is  shown  by  many 
persons,  is  not  peculiar  to  tuberculosis,  but  exists  with  relation 
to  all  of  the  infectious  diseases.  If  a  number  of  persons  drink 
typhoid  bacilli  in  water,  only  a  small  percentage  of  them  will 
contract  typhoid  fever,  the  others  escaping.  Similar  con- 
ditions exist  with  regard  to  the  other  infectious  diseases.  The 
frequent  occurrence  of  several  cases  of  pulmonary  tuberculosis 
in  a  family  is,  then,  to  be  explained,  not  on  the  supposition  that 
the  disease  itself  has  been  inherited,  as  this  is  of  excessively 
rare  occurrence,  but  that  it  has  been  produced  after  birth  by 
direct  transmission  from  some  affected  individual.  Most  of 
these  recurring  cases  in  successive  generations  in  the  same 
family  result  from  direct  transmission  or  house  infection.  The 
houses  which  have  been  occupied  by  consumptives  become  in- 
fected, and  thus  the  disease  is  transmitted  to  other  members 
of  the  family.  Where  the  parents  are  affected  with  tubercu- 
losis the  children  from  the  earliest  moments  of  life  are  exposed 
to  the  disease  under  the  most  favorable  conditions  for  its  trans- 
mission, for  not  only  is  the  dust  of  the  house  likely  to  contain 
the  bacilli,  but  the  relationship  between  parents  and  children, 
especially  between  mother  and  child,  are  of  that  close  and  inti- 
mate nature  most  favorable  for  the  transmission  by  direct  con- 
tact. In  relation  to  this  I  may  quote  from  Dr.  Knopf's  essay 
on  tuberculosis : 

"The  most  common  modes  of  infection  during  early  child- 
hood are  perhaps  the  following:  The  consumptive  mother 
caresses  the  child  and  kisses  it  on  the  mouth;  she  prepares  the 
food,  tasting  it  to  judge  its  temperature  and  flavor,  through 
the  same  rubber  nipple  or  with  the  same  spoon  the  child  uses, 
and  thus  unconsciously  conveys  the  germs  of  her  disease  from 
her  own  mouth  to  that  of  the  child.  Later  on  the  child  will 
play  on  the  floor  of  the  room,  and  should  there.be  a  consump- 
tive in  the  family,  who  from  carelessness  or  ignorance  is  not 
careful  in  the  disposal  of  his  expectoration,  the  child  is  indeed 

163 


likely  to  be  infected.  The  little  one,  while  playing  on  the 
floor,  may  with  great  facility  inhale  the  bacilli  floating  with 
the  dust  in  the  air  and  can  thus  acquire  tuberculosis  by  in- 
halation, the  full  development  of  which  may  only  take  place  in 
later  years,  when  the  origin  will  not  be  thought  of.  Again, 
the  little  child  touches  everything  it  can  take  hold  of,  infecting 
its  fingers  thoroughly,  and  by  putting  them  in  its  mouth  tuber- 
culosis by  ingestion  may  result  and  gradually  develop  into  con- 
sumption of  the  bowels.  Lastly,  should  the  child's  nails  be 
neglected  it  may  scratch  itself  with  the  infected  fingers,  and 
thus  inoculate  its  system  with  the  disease.  Tuberculosis  of  the 
skin,  or  lupus,  may  result  from  such  an  unfortunate  accident. 

"To  prevent  these  infections  during  childhood  is  certainly 
possible  by  taking  the  following  precautions :  Not  only  should 
consumptives  be  religiously  careful  with  their  expectoration, 
but  they  should  associate  as  little  as  possible  with  young  chil- 
dren, and  stay  away  from  playrooms  and  playgrounds.  We 
repeat  that  to  kiss  children  on  the  mouth  should  never  be 
allowed  and  the  little  ones  should  be  taught  never  to  kiss  nor 
be  kissed  by  strangers.  They  should  be  kissed  by  their  own 
friends  and  relatives  as  little  as  possible  and  then  only  on  the 
cheeks.  The  floor  on  which  the  child  plays  should  be  kept 
scrupulously  clean.  Carpets  in  such  a  place  are  an  abomina- 
tion; they  only  serve  as  dust  and  dirt  collectors,  and  not  infre- 
quently harbor  the  germs  of  contagious  diseases.  The  hands 
and  nails  of  little  children  should  be  kept  as  clean  as  possible. 

"Expectorating  on  playgrounds  should  be  considered  a 
grave  offence  and  should  be  punished  accordingly.  These 
playgrounds  should  be  kept  clean,  as  free  from  dust  as  possi- 
ble, and  daily  strewn  with  clean  sand  or  gravel." 

Aside  from  infection  through  the  inhalation  of  dust  which 
contains  tubercle  bacilli,  we  may  sometimes  have  the  disease 
produced  by  the  ingestion  of  food  containing  these  germs.  It 
is  well  known  that  many  domestic  animals,  and  especially 
cows,  are  particularly  susceptible  to  tuberculosis,  and  that  the 
meat  and  milk  of  such  an  infected  animal  may  contain  tubercle 
bacilli.     This  mode  of  infection  was  formerly  regarded  as  a 

164 


very  important  one,  but  the  feeling  has  been  growing  stronger 
and  stronger  among  scientific  men  that  this  is  a  less  serious 
source  of  danger  than  was  formerly  believed.  Considerable 
doubt  has  been  thrown  upon  its  occurrence  by  the  observations 
of  Koch. 

These  observations  seem  to  show  that  tuberculosis  is  not 
readily  transmitted  from  cattle  to  human  beings,  although  this 
has  not  been  definitely  proven.  The  explanation  of  this  fact, 
if  true,  is  that  the  tubercle  bacilli  which  cause  the  disease  in 
cattle  have  been  somewhat  modified  in  character  by  long  resi- 
dence in  the  bovine  species,  and  as  a  result  have  lost  a  portion 
of  their  disease-producing  power  in  the  human  being.  This, 
no  doubt,  can  be  readily  acquired  again  under  special  con- 
ditions. We  have  in  other  forms  of  disease  illustrations  of  this 
same  thing.  Small-pox  and  cow-pox,  or  vaccinia,  the  disease 
from  which  vaccine  virus  is  obtained,  are  undoubtedly  both 
the  result  of  the  same  kind  of  an  infection.  Still  it  is  difificult 
to  produce  cow-pox  by  the  direct  inoculation  of  the  bovine 
species  with  small-pox  virus,  but  if  monkeys  are  first  inocu- 
lated with  small-pox  virus  and  then  the  cows  inoculated  from 
monkeys,  cow-pox  results,  the  virus  being  modified  sufficiently 
in  its  passage  through  monkeys  to  render  the  cow  then  sus- 
ceptible. While,  therefore,  holding  in  abeyance  a  final  decision 
in  regard  to  the  danger  to  human  beings  from  the  prevalence 
of  tuberculosis  in  cattle,  it  seems  quite  certain  that  the  serious- 
ness of  the  danger  of  infection  from  this  source  has  been  some- 
what overestimated.  From  what  has  been  said,  it  follows : 
(i)  That  tuberculosis  is  a  distinctly  preventable  disease;  (2) 
that  it  is  not  directly  inherited ;  and  (3)  that  it  is  acquired  by 
direct  transmission  of  the  tubercle  bacillus  from  the  sick  to 
the  well,  usually  by  means  of  the  dried  and  pulverized  sputum 
floating  as  dust  in  the  air. 

It  may  be  worth  while  now  to  estimate  briefly  the  annual 
cost  to  the  community  of  tuberculosis. 

During  the  last  twenty  years  there  has  been  a  reduction  in 
the  death-rate  from  tubercular  diseases  in  New  York  City  of 
nearly  forty  per  cent.     The  total  number  of  deaths  in   1901 

165 


ascribed  to  this  disease  in  New  York  City  was  9412.  For  the 
Boroughs  of  Manhattan  and  the  Bronx  alone,  concerning  which 
we  have  more  accurate  data  for  a  series  of  years,  we  find  that 
during  the  past  twenty  years  there  has  been  an  actual  decrease 
in  the  total  number  of  deaths,  notwithstanding  an  increase  of 
population;  that  is,  in  1881  the  deaths  from  the  tuberculous 
diseases  in  the  Boroughs  of  Manhattan  and  the  Bronx  num- 
bered 6123;  in  1901,  twenty  years  later,  they  numbered  6051. 
During  this  time  the  population  of  these  Boroughs  had  in- 
creased nearly  70  per  cent.,  viz.,  from  a  little  over  1,200,000 
to  more  than  2, 100,000.  Taking  now  the  deaths  for  the  whole 
of  New  York  City,  annually,  at  10,000,- — as  we  may  safely  as- 
sume that  several  hundred  deaths  each  year  which  should  be 
ascribed  to  the  tubercular  diseases  are  ascribed  to  some  other 
cause, — we  may  estimate  the  economic  loss  to  the  municipality. 
It  may  be  conservatively  estimated  that  each  human  life  at  the 
average  age  at  which  the  tubercular  deaths  occur  is  worth  to 
the  municipality  $1500.  The  cost  of  each  life  at  this  age  is 
usually  more  than  this.  This  gives  a  total  value  to  the  lives 
lost  annually  of  $15,000,000. 

We  may  further  assume  that  for  an  average  period  of  at  least 
nine  months  these  persons  are  unable  to  work  and  must  be 
cared  for.  The  loss  of  their  service  during  this  period  may  be 
estimated  at  $i  a  day,  and  the  cost  of  food,  nursing,  medicines, 
attendance,  etc.,  at  $1.50  more  per  day,  making  a  further  loss 
of  $2.50  per  day,  for  each  person  dying,  for  a  period  of  270  days. 
This  gives  us  a  further  loss  to  the  municipality  of  $8,000,000, 
making  a  total  annual  loss  to  the  city  from  tubercular  diseases 
of  at  least  $23,000,000.  It  has  been  estimated  that  in  the 
United  States  annually  not  less  that  150,000  deaths  are  caused 
by  the  tubercular  diseases,  and  estimating  the  value  of  these 
on  the  basis  just  given,  we  have  an  annual  loss  to  the  country 
of  more  than  $330,000,000. 

■  This  method  of  estimating  the  importance  of  the  work  in 
the  prevention  of  tuberculosis  may  seem  unfeeling,  but  it  is  an 
economic  view  and  one  which  should  appeal  to  the  various 
state  and  city  officials.     I  have  not  the  slightest  doubt,  per- 

166 


sonally,  after  a  very  large  experience  in  the  sanitary  supervision 
of  infectious  diseases  in  New  York  City  covering  many  years, 
that  the  expenditure  of  a  small  part,  annually,  of  this  sum 
would  result  in  a  very  rapid  decrease  in  the  prevalence  of  the 
tuberculous  diseases  in  this  country. 

A  system  of  registration  of  all  tuberculous  cases  has  been  in 
force  in  New  York  for  many  years.  Last  year  there  were  re- 
ported to  the  Department  of  Health  more  than  13,000  new 
cases.  It  may  be  safely  estimated  that  this  represents  less 
than  one-half  of  the  cases  actually  existent  in  New  York  City, 
for  many  cases  live  for  several  years  after  they  are  brought  to 
the  attention  of  the  Department  and  are  only  included  when 
originally  reported,  and  many  are  not  reported  at  all.  For 
example,  nearly  5000  other  cases  were  reported  in  1901,  which 
had  been  previously  reported.  I  think  we  may  safely  estimate 
that  30,000  cases  of  tuberculosis  in  a  stage  of  the  disease  in 
which  it  could  be  easily  recognized  by  a  competent  physician 
are  present  in  New  York  City. 

I  have  had  a  census  of  the  cases  actually  under  treatment  in 
the  hospitals  in  New  York  City  made  annually  for  a  series  of 
years,  and  the  total  number  never  much  exceeded  1000,  or  less 
than  four  per  cent,  of  the  cases  actually  present  in  the  city. 
The  vast  proportion  of  the  remainder  are  in  tenement  houses. 
I  have  estimated  that  the  total  expenditure  in  the  city  of  New 
York  in  its  public  institutions  for  the  care  and  treatment  of 
tuberculous  patients  is  not  over  $500,000  a  year,  or  not  more 
than  two  per  cent,  of  the  actual  loss  to  the  city  annually.  If 
this  annual  expenditure  were  doubled  or  trebled  it  would  mean 
a  saving  of  several  thousand  lives  annually,  to  say  nothing  of 
the  enormous  saving  in  suffering. 

It  is  now  fifteen  years  since  the  New  York  City  Health  De- 
partment first  began,  in  a  very  small  way,  its  efforts  for  the 
prevention  of  tuberculosis,  and  these  have  been  rewarded  by 
a  reduction  in  the  mortality  all  out  of  proportion  to  the  ex- 
penditure in  money  and  time  which  has  been  made.  Still, 
more  has  been  done  in  New  York  than  in  almost  any  city  in 
the  world.     The  measures,  however,  now  in  force  are  quite 

167 


inadequate,  as  compared  with  the  importance  and  magnitude 
of  the  problem.  The  sanitary  authorities,  however  enthusi- 
astic and  efficient,  and  the  medical  profession,  however  influ- 
ential and  numerous,  cannot  grapple  with  this  problem  unless 
they  have  the  hearty  support  of  the  people  and  the  adminis- 
tration of  the  city.  They  must  have  generous  appropriations 
for  carrying  on  the  work — for  the  provision  of  medical  in- 
spectors and  disinfectors,  for  educational  measures,  for  the 
establishment  of  dispensaries  and  sanatoria  for  the  care  of  in- 
cipient cases,  and  of  homes  to  which  advanced  cases  may  be 
removed,  and  where  they  may  be  made  comfortable  until  the 
inevitable  fatal  termination  comes.  We  must  remember,  in 
this  connection,  that  every  incipient  case  and  every  advanced 
case  of  tuberculosis  which  is  removed  from  its  home  and  sur- 
roundings and  placed  in  a  properly  equipped  and  conducted 
institution  is,  in  this  way,  not  only  given  a  fair  chance  for  re- 
covery of  health,  but  is  educated  as  to  the  means  to  be  taken 
to  prevent  further  extension  of  infection,  and,  at  the  same 
time,  one  focus  of  infection  is  removed  from  the  city.  On  the 
average,  every  case  of  tuberculosis  infects  at  least  one  other 
case,  and  if  removed  to  a  hospital  early  enough,  the  infection 
of  this  second  case  would  be,  in  each  instance,  prevented,  and 
thus  the  total  number  of  cases  would  be  reduced. 

It  is  in  an  educational  way  that  lay  organizations  for  the 
prevention  of  tuberculosis  may  be  of  the  greatest  service. 
They  serve  to  arouse  interest  in  and  to  disseminate  knowledge 
of  the  nature  of  tuberculosis;  they  form  compact  bodies  of 
public-spirited  citizens,  whose  influence  is  of  the  greatest  value 
in  so  moulding  public  sentiment  that  funds  shall  be  forthcom- 
ing to  erect  and  maintain  dispensaries,  sanatoria,  and  homes 
for  the  consumptive  poor.  Through  their  assistance  and  that 
of  the  public  press,  we  may  hope  eventually  to  obtain  state 
and  municipal  appropriations  for  the  suitable  care  of  the  con- 
sumptive poor.  New  York  State  has  made  a  small  beginning 
in  this  way,  and  it  is  hoped  that  the  State  sanatorium,  now  in 
course  of  erection  in  the  Adirondacks,  may  lead  to  very  much 
larger  appropriations  for  this  purpose.     The  state  is  spending 

168 


many  millions  of  dollars  annually  for  the  care  of  the  insane, 
and  while  this  is  absolutely  necessary  for  humanitarian  reasons, 
I  have  no  hesitation  in  saying  that  far  greater  returns  would 
be  obtained  from  the  expenditure  of  one-quarter  the  amount 
in  the  prevention  and  cure  of  tubercular  disease. 

I  believe  that  tuberculosis  may  be  practically  stamped  out. 
The  reduction  in  the  mortality  from  it  in  New  York  City  since 
1886  has  been  about  forty  per  cent.,  which  means  if  applied  to 
the  Greater  City  a  decrease  of  more  than  6000  in  the  number 
of  deaths  annually  caused  by  it.  The  vast  significance  of  this 
is  still  more  enhanced  when  we  remember  that  to  a  very  large 
extent  these  deaths  take  place  in  the  working  period  between 
fifteen  and  iifty-five  years  of  age.  I  have  no  doubt  that  the 
measures  first  begun  in  a  very  small  way  in  New  York  City 
fifteen  years  ago,  inadequate  as  they  have  been,  have  resulted 
in  saving  the  lives  of  at  least  twenty  thousand  persons.  The 
annual  deaths  in  the  Greater  City  still  number  between  nine 
and  ten  thousand,  and  we  know  that  these  are  to  a  very  large 
extent  unnecessary. 


169 


Appendix  7 

THE  DUTIES  OF  THE  INDIVIDUAL  AND 
THE  GOVERNMENT  IN  THE  COM- 
BAT OF  TUBERCULOSIS 

By  S.  A.  KNOPF,  M.D.,  New  York 

Hon.  Vice-President,  British  Congress  on  Tuberculosis  ;  Attending  Physician  to 
the  Riverside  Sanatorium  for  Consumptives  of  the  City  of  New  York  ; 
Consulting  Physician  to  Gabriels  Sanatorium  for  Consump- 
tives, Gabriels,   N.  Y.;  etc. 


171 


THE    DUTIES    OF    THE    INDIVIDUAL    AND    THE 

GOVERNMENT    IN    THE    COMBAT    OF 

TUBERCULOSIS 

By  way  of  preface,  I  desire  to  state  that  I  shall  speak  not 
only  of  the  duty  of  the  government  but  particularly  of  the 
duties  of  individuals,  represented  by  the  consumptives  them- 
selves, those  living  with  them,  the  general  public,  the  teachers, 
the  clergy,  the  gentlemen  of  the  press,  and  the  philanthropists. 
I  might  be  asked  why  I  do  not  say  anything  of  the  duties  of 
the  physician.  Let  me  assure  you  that  the  medical  profession 
is  fully  aware  of  its  great  duties  and  responsibilities  in  this 
struggle  against  tuberculosis.  Many  of  you  have  doubtless 
heard  of  the  numerous  interesting  discussions  in  the  various 
medical  assemblies.  The  duties  of  the  physician  in  this  matter 
are,  of  course,  of  a  specific  character,  and  his  curative  and  pre- 
ventive measures  in  dealing  with  the  tuberculosis  problem  have 
been  amply  discussed  before  medical  audiences. 

Whenever  there  is  an  enemy  to  fight  we  must  know  his  strong 
and  his  weak  points,  and  the. more  intimately  we  are  acquainted 
with  his  strength  and  his  weakness,  the  more  likely  we  are  to 
become  victorious  over  him.  Let  us  therefore  consider  for  a 
moment  the  character  and  the  peculiarities  of  the  disease  we 
are  desirous  to  combat. 

DEFINITION  OF  PULMONARY  TUBERCULOSIS 

Pulmonary  tuberculosis,  or  consumption,  is  a  chronic,  in- 
fectious, and  communicable  disease,  caused  by  the  presence  of 

173 


the  tubercle  bacillus,  or  germ  of  consumption,  in  the  lungs. 
The  disease  is  locally  characterized  by  countless  tubercles — that 
is  to  say,  small  rounded  bodies,  visible  to  the  naked  eye.  The 
bacilli  can  be  found  by  the  million  in  the  affected  organ.  It 
is  this  little  parasite,  fungus,  or  mushroom,  belonging  to  the 
lowest  scale  of  vegetable  life,  which  must  be  considered  as  the 
specific  cause  of  all  tuberculous  diseases.  This  parasite  not 
only  gradually  destroys  the  lung  substance  through  ulcerative 
processes,  but  at  the  same  time  gives  off  certain  poisonous 
substances,  called  toxins,  which  give  rise  to  various,  and  often 
serious,  symptoms. 

The  important  symptoms  of  pulmonary  tuberculosis  are 
cough,  expectoration  (spitting  phlegm),  fever  (increased  tem- 
perature of  the  body,  especially  in  the  evening  hours),  difficulty 
in  breathing,  pains  in  the  chest,  night-sweats,  loss  of  appetite, 
hemorrhages  (spitting  of  blood),  and  emaciation  (loss  of  flesh). 
In  the  matter  expectorated  it  is  often  possible  to  find  the 
tubercle  bacillus  with  the  aid  of  the  microscope  and  certain 
coloring  matters.  It  appears  in  the  form  of  small,  slender 
rods. 

How  may  this  germ  of  consumption  enter  the  human  system? 

METHODS    OF    ENTRANCE    OF    THE    GERM    INTO    THE    HUMAN 

SYSTEM 

There  are  really  three  methods  whereby  this  germ  may 
enter:  namely,  by  inhalation — that  is,  being  breathed  into  the 
lungs;  by  ingestion — that  is,  being  eaten  with  tuberculous 
food ;  and  by  inoculation — that  is,  the  penetration  of  tubercu- 
lous substance  through  a  wound  in  the  skin. 

INHALATION 

Let  us  treat  first  the  most  frequent  method  of  the  propagation 
of  tuberculosis,  namely,  that  arising  from  the  indiscriminate 
deposit  of  the  tuberculous  sputum.  A  consumptive  individual, 
even  at  a  period  when  he  is  not  confined  to  his  bed,  may  ex- 

174 


pectorate  enormous  quantities  of  bacilli.  Now,  if  his  expec- 
toration, or  spittle,  is  carelessly  deposited  here  and  there  so 
that  it  has  an  opportunity  to  dry  and  become  pulverized,  the 
least  draught  or  motion  of  the  air  may  cause  it  to  mingle  with 
the  dust,  and  the  individual  inhaling  this  dust-laden  atmosphere 
is  certainly  exposed  to  the  danger  of  becoming  tuberculous  if 
the  system  offers  a  favorable  soil  for  the  growth  of  the  bacilli. 
By  "favorable  soil  for  the  growth  of  bacilli"  must  be  under- 
stood any  condition  in  which  the  body  is  temporarily  or  per- 
manently enfeebled.  Such  a  condition  may  be  inherited  from 
parents,  or  acquired  through  alcoholism,  or  drunkenness,  or 
other  intemperate  habits,  through  privation,  or  disease. 

DROP   INFECTION 

Besides  the  danger  arising  from  carelessly  deposited  sputum, 
or  spittle,  the  inhalation  or  ingestion  of  the  small  particles  of 
saliva  which  may  be  expelled  by  the  consumptive  during  his 
so-called  dry  cough,  when  speaking  quickly  or  loudly,  or  when 
sneezing,  must  also  be  considered  as  dangerous  for  those  who 
come  in  close  contact  with  the  invalid.  These  almost  invisible 
drops  of  saliva  may  contain  tubercle  bacilli.  Recent  experi- 
ments in  this  direction  have  shown  the  possibility  of  infection 
by  this  means. 

The  next  most  frequent  method  of  the  propagation  of  tuber- 
culosis is  through  the  ingestion  of  the  bacilli — that  is  to  say, 
when  the  germ  of  consumption  is  taken  with  the  food. 

The  third  and  much  less  frequent  way  of  the  cause  of  tuber- 
culosis is  the  inoculation,  or  penetration  of  the  tuberculous 
substance  through  the  skin. 

What  should  we  do  to  stop  the  first  and  most  frequent 
source  of  the  dissemination  of  the  bacillus? 

A  patient  suffering  from  pulmonary  consumption  should 
know  that  no  matter  in  what  stage  of  the  disease  he  may  be, 
his  expectoration,  or  spittle,  may  spread  the  germ  of  the  dis- 
ease if  the  matter  expectorated  is  not  destroyed  before  it  has 
a  chance  to  dry  and  become  pulverized.     The  patient  should, 

175 


therefore,  always  spit  in  some  receptacle  intended  for  that 
purpose.  It  is  best  to  have  this  vessel  made  of  metal  so  as  not 
to  break.  It  should  be  half  filled  with  water  or  some  disinfect- 
ing fluid,  the  main  thing  being  to  make  it  impossible  for  the 
expectoration  to  dry. 


Fig.  I — Elevated  Spittoon,  Entirely  of 
Metal — When  in  Use. 


Fig.   2— The  Same, 
Closed. 


In  factories,  stores,  railroad  cars,  waiting-rooms,  court-rooms, 
restaurants,  saloons,  meeting-places,  theatres,  menageries, — in 
short,  wherever  many  people  congregate, — there  should  be  a 
sufficient  number  of  cuspidors  well  kept  and  regularly  cleaned. 
They  should  be  made  of  unbreakable  material  and  have  wide 
openings.  If  such  measures  are  carried  out,  there  will  be  no 
excuse  for  any  one  to  expectorate  on  the  floor  and  thus  en- 
danger the  lives  of  his  fellow-men. 

A  handkerchief  should  never  be  used  as  a  receptacle  for 
sputum.     Patients  who  are  too  sick  to  make  use  of  light  porce- 

176 


lain  or  aluminum  cups,  should  have  a  number  of  moist  rags 
within  easy  reach.  Care  should  be  taken  that  the  rags  always 
remain  moist,  and  that  the  used  ones  are  burned  before  they 
have  a  chance  to  dry.  The  paper  spit-cups  with  their  contents 
should,  of  course,  also  be  destroyed  by  fire. 

For  the  use  in  public  institu- 
tions, in  corridors,  and  grounds, 
I  would  recommend  an  elevated 
spittoon  (Figs,  i  and  2),  which  has 
numerous  advantages  over  the 
ordinary  spittoon  placed  on  the 
floor.  The  latter  is  unsightly, 
may  be  tipped  over,  and  usually 
presents  on  its  rim  or  on  the 
outside  dried  sputum  which  did 
not  reach  the  receptacle  proper. 
Having  no  cover,  these  old-fash- 
ioned cuspidors  allow  animals  and 
insects  to  get  at  the  contents  and 
thus  help  in  the  dissemination  of 
the  bacilli. 

The  stand  of  the  elevated  spit- 
toon is  three  and  one-half  feet  in 
height,  and  consists  of  iron  tub- 
ing with  a  bottom  plate,  which 
can  be  screwed  on  to  the  floor  or 
fastened  to  a  sunken  board  when 
used  out-of-doors.  The  large  cast- 
iron  base,  however,  is  in  itself 
sufftciently  heavy  to  prevent  the 

spittoon  from  tipping  over.  On  top  of  this  tube  is  a  round 
box  of  sheet  iron,  with  a  door  which  can  be  tightly  closed. 
Attached  to  this  door  is  a  ring  in  which  rests  a  blue  or  white 
enamelled  iron  spittoon.  Thus,  when  the  box  is  opened  the 
spittoon  is  drawn  forward  and  ready  for  use.  The  top  of  the 
stand  is  provided  with  a  rim  to  facilitate  the  placing  of  a  flower- 
pot or  other  ornament.      These  elevated  spittoons,  only  visible 

177 


Fig.   3 — Elevated    Spittoon,    Stand 
of  Wood,  Open. 


when  in  use,  by  their  convenient  height  and  easy  manipulation, 
make  the  deposit  of"  the  sputum  into  the  cuspidor  more  certain 
than  in  the  case  where  spittoons  are  placed  on  the  floor. 

A  similar  elevated  spittoon  stand  can 
be  made  of  wood,  which  would  make  it 
considerably  cheaper.     (See  Fig.  3.) 

Proedohl's  enamelled  iron  spittoon  (Fig, 
4)  and  its  modifications  (Figs.  4a,  4b,  and 
4c)  can  be  suspended  at  any  height,  and 
are  particularly  suitable  for  use  in  work- 
shops, factories,  and  schools. 

For  street  use,  particularly  in  health 
resorts,  I  have  devised  the  following  re- 
ceptacle which  might  deserve  the  name 
"public  self-cleansing  spittoon  "  (Fig.  5). 
It  is  thirty  -  nine  inches  in  height,  sup- 
ported by  heavy  tubing;  the  receptacle 
is  made  of  heavy  copper  coated  with  pure 
tin  on  the  inside,  to  the  upper  edge  of 
which  is  screwed  a  perforated  lead  pipe  which  supplies  the 
water    for   constant    flushing.     The   receptacle  is  nine  inches 


Fig.  4  —  Proedohl's 
Enamelled  Iron  Spit- 
toon, to  be  Suspended 
at  Convenient  Height. 


Fig.  4a — Wall  Cuspidor  of 
Metal,  Open. 


Fig.  4b — Wall  Cuspidor  of 
Metal,  Closed. 


in  diameter,   five  inches  deep,  with  a  funnel-shaped  bottom 
three  inches  deep,  fitting  into  a  two-inch  iron  cylinder  support, 

178 


which  also  serves  as  a  connection  sewer,  and  this  support  is 
attached  to  a  heavy  cast-iron  base.  The  lead-pipe  water  sup- 
ply passes  along  the  inside  of  the  apparatus  and  can  be  attached 
to  any  hydrant. 


Fig.  4c — Wall  Cuspidor  of  Metal  in  Use. 


Fig.  5 — Elevated  Self-Cleans- 
ing Street  Spittoon. 


When  outdoors,  the  patient  should  use  a  pocket  flask  of 
metal,  strong  glass,  or  pasteboard.  There  are  numerous  kinds 
of  these  in  the  market. 

I  show  you  here  a  little  model  which,  perhaps,  answers  all 
the  requirements  (Figs.  6,  7,  and  8).  As  you  see  it  is  oval  in 
shape  and  can  be  conveniently  placed  in  a  pocket.  It  is  about 
three  and  three-quarters  inches  in  height,  its  longest  diameter 
is  two  and  three-quarters  inches,  and  its  shortest  diameter  one 
and  one-half  inches.     The  opening  is  round  and  has  a  diameter 

179 


of  one  and  one-half  inches.  A  movable  funnel  prevents  the  con- 
tents from  soiling  the  cover,  acting  on  the  principle  of  the 
reversible  inkstand.  The  flask 
is  made  of  spring  brass  and  is 
electro  -  nickel  -  plated.  Two 
seamless  brass  cups  are  welded 
together,  forming  the  flask,  to 
which  the  cover  is  firmly  sold- 
ered and  the  funnel  spun  (seam- 
less) with  a  flange  fits  exactly  on 


Fig.  6  —  Nickel  -  plated,  Oval  - 
shaped  Pocket  Flask.  Manage- 
able with  One  Hand. 


Fig.   8 — Method  of  Empty- 
ing the  Flask. 

the  rim  of  the  cup.  The  cover 
is  closely  fitted  with  an  elastic 
rubber  ring  for  the  purpose  of 
preventing  leakage.  There  is 
a  strong  spring  catch  which 
serves  for  opening  and  closing, 
and  the  flask  can  be  manipulated  with  one  hand  by  pressing 

180 


Fig.  7 — The  Same,  Hidden  in  the  Folds 
of  a  Handkerchief. 


with  the  thumb  against  the  opening  spring  and  closing  the 
cover  with  the  index  finger.  By  the  aid  of  a  wire  hook  the 
funnel  can  easily  be  removed  and  the  flask  emptied.  By 
placing  the  flask  in  the  centre  of  a  moderate-sized  handkerchief, 
taking  up  the  four  corners,  and  putting  an  elastic  band  around 
the  neck  of  the  flask  outside  of  the  handkerchief  the  cuspidor 
can  be  used  without  attracting  any  attention. 

I  also  show  you  here  a  few  other  less  expensive  pocket  metal 
flasks  (Figs.  9  and  10)  and  paper  spit-cups  and  purses  (Figs. 
1 1  and  12)  which  may  answer  the  purpose  just  as  well.  Some 
of  these,  such  as  the  Dettweiler  flask  (Fig.  13)  and  its  modifi- 
cation, the  one  illustrated  in  Fig.  14,  are  made  of  blue  glass. 

For  use  at  the  bedside  such  sputum  cups  as  are  illustrated  in 
Figs.  15,  16,  and  17,  made  of  pasteboard,  or  such  as  is  shown 
in  Fig.  18,  made  of  light  metal,  are  most  convenient. 

There  will  always  be  some  consumptives  who  cannot  be  per- 
suaded to  use  the  pocket  flask,  for  the  simple  reason  that  they 
do  not  wish  to  draw  attention  to  their  malady.  The  only 
thing  for  these  people  to  do  is  to  use  squares  of  soft  muslin, 
cheese-cloth,  cheap  handkerchiefs,  or  Japanese  paper  handker- 
chiefs specially  manufactured  for  that  purpose,  which  can  be 
burned  after  use.  They  should  also  place  in  their  pockets  a 
removable  lining  of  rubber  or  other  impermeable  substance 
which  can  be  thoroughly  cleaned.  This  additional  pocket 
could  be  fastened  to  the  inside  of  the  ordinary  pocket  by 
clamps,  and  would  thus  be  of  no  inconvenience  to  the  patient. 
A  pouch  of  vulcanized  rubber  or  an  oriental  tobacco-pouch  may 
be  used  in  place  of  the  extra  pocket  of  impermeable  material. 

The  danger  of  dissemination  of  the  bacilli  through  the  so- 
called  dry  cough  (drop  infection)  is  relatively  small ;  we  should, 
however,  insist  that  the  patient  hold  a  handkerchief  before  his 
mouth  or  nose  when  he  coughs  or  sneezes.  The  consumptive 
should  be  advised  to  carry  two  handkerchiefs  with  him,  one  to 
hold  before  his  mouth  and  to  wipe  it  with  after  having  ex- 
pectorated ;  the  other  to  use  only  to  wipe  his  nose.  By  being 
careful  with  the  use  of  his  handkerchiefs,  the  danger  of  infect- 
ing his  nose  and  bronchial  tubes  will  be  materially  lessened. 

181 


Fig.  9  —  Round- 
shaped,  Nickel- 
plated  Pocket 
Flask.  Man- 
ageable w  i  t  li 
One  Hand. 


Fig.  lo — Cheap 
Metal  Flask, 

with  Bayonet         Fig.  ii — Pasteboard  Sputum  Case,  Re- 
Closure,  sembling  Cigar  Case. 


Fig.  12 — Pasteboard  Purse. 


Fig.     13  —  Dett-  Fig.     14  —  Blue    Glass    Sputum 

weiler's  Pocket  Flask.     Manageable  with  One 

Flask.  Hand. 
183 


All  soiled  linens  (sheets,  pillow-cases,  underwear,   napkins,- 
handkerchiefs,  etc.)  used  by  the  consumptives  should  not  be 


Fig.   14a — Blue  Glass  Sputum  Flask 
with  Dettweiler  End  Piece. 


Fig.    15  — Frame  for  Seabury  & 
Johnson's  Sputum  Cup. 


Fig.  16 — Pasteboard  Cup 
for  Seabury  &  Johnson's 
Frame. 


Fig.  17 — Pasteboard  .Sputum  Cup  for  Bedside. 


Fig.  18— Metal  Spit- 
Cup  for  Bedside. 


handled  more  than  necessary,  but  should  be  placed  in  water  as 
soon  as  possible  after  removal  from  the  bed  or  body.  It  is 
better  to  wash  these  articles  separately,  and  only  after  having 

1^3 


been  thoroughly  boiled  should  they  be  put  with  the  common 
laundry.  Whenever  it  is  not  possible  to  carry  out  these  pre- 
cautionary measures  in  their  entirety,  one  should  strive  to  fol- 
low them  as  far  as  it  is  in  one's  power. 

INGESTION   OF   TUBERCULOUS   FOOD 

Against  the  danger  from  infection  through  tuberculous  food 
we  will  say  that  whenever  one  is  not  reasonably  certain  that 
the  meat  he  eats  has  been  carefully  inspected  and  declared  free 
from  disease  germs,  it  should  be  very  thoroughly  cooked.  By 
this  means  one  is  certain  to  kill  all  the  dangerous  micro- 
organisms. Against  the  sale  of  tuberculous  milk,  there  are 
very  excellent  laws  in  some  States  of  the  Union  which  are 
rigorously  enforced.'  In  some  the  laws  are  less  good,  and  in 
some  there  are  no  laws  at  the  present  time.  In  justice  to 
farmers  and  dairymen  it  must,  however,  be  said  that  there  are 
many  who  do  their  very  best  to  protect  themselves  and  their 
fellow-men  from  the  danger  of  tuberculosis.  They  have  their 
cows  tested  regularly,  destroy  the  animals  which  are  found  to 
be  tuberculous,  and  keep  their  stables  and  utensils  for  milk  as 
clean  as  possible.  Unless  one  can  be  reasonably  sure  that  the 
cows  from  which  the  milk  is  derived  are  healthy  and  not  tuber- 
culous, the  milk  should  be  boiled  or  sterilized  before  use,  espe- 
cially when  it  is  intended  as  food  for  children.  Milk  obtained 
from  stores  and  from  milk  peddlers  should  invariably  be  sub- 
mitted to  boiling  or  sterilization.  When  milk  is  kept  slowly 
boiling  for  five  minutes,  all  the  bacilli  are  killed,  and  the  same 
result  is  obtained  by  the  sterilizing  process — that  is  to  say,  to 
keep  the  milk  heated  for  at  least  half  an  hour  at  a  temperature 
of  about  70  degrees  Centigrade  or  160  degrees  Fahrenheit. 
There  are  now  in  the  market  a  number  of  cheap  and  practical 
apparatuses  for  sterilizing  milk  which  can  be  obtained  at  almost 
any  drug  store. 

Raw  fruit  bought  from  the  push-cart  man,  or,  for  that  mat- 
ter, derived  from  any  other  source,  should  be  washed,  peeled, 
or  cooked  before  being  eaten. 

184 


There  is  another  possibiHty  whereby  the  germs  of  consump- 
tion may  enter  our  stomachs  or  intestines,  namely,  through 
kissing  the  consumptive,  or  using  utensils  which  have  been 
soiled  by  the  saliva  of  the  patient.  Therefore,  the  consump- 
tive should  never  kiss,  no  matter  whom,  on  the  mouth,  and 
children  should  be  taught  not  to  allow  any  one  to  kiss  them 
except  on  the  cheek  or  not  at  all.  Tuberculous  patients  should 
have  their  own  drinking  glasses,  spoons,  forks,  etc.  ;  or,  at  least, 
all  table  utensils  which  have  served  the  tuberculous  patient 
should  be  sterilized  in  boiling  water  after  use. 

It  is,  of  course,  also  possible  that  the  consumptive  may  con- 
tract intestinal  tuberculosis  when  he,  out  of  false  modesty, 
swallows  his  expectoration.  He  should  also  remember  never 
to  touch  food  before  having  washed  his  hands  very  thoroughly. 
Even  with  the  greatest  care  it  is  possible  that  he  may  have 
soiled  his  hands  with  tuberculous  expectoration. 

INFECTION   BY    INOCULATION 

Inoculation,  or  the  penetration  of  tuberculous  substance 
through  the  skin,  happens  perhaps  most  frequently  through 
injuries  received  while  cleaning  nickel  or  chipped  glass  or 
porcelain  cuspidors  which  have  been  used  by  consumptives. 
It  is  also  possible  for  the  bacilli  to  enter  the  circulation  if  the 
person  cleaning  the  spittoons  happens  to  have  a  wound  or 
open  sore  on  his  hands.  Persons  intrusted  with  the  care  of 
the  spittoons  in  a  private  home  or  an  institution  for  con- 
sumptives should  wear  rubber  gloves  while  cleaning  these 
vessels.  At  times  the  patient  may  inoculate  himself  by  placing 
an  accidentally  injured  finger  in  his  mouth,  or  by  carelessly 
soiling  an  open  wound  with  his  expectoration.  Physicians, 
students  of  medicine  or  veterinary  science,  butchers,  etc., 
are  also  exposed  to  the  danger  of  wounding  themselves  with 
instruments  which  may  have  come  in  contact  with  tuberculous 
matter.  Extreme  care  is  the  only  remedy  for  all  persons  thus 
exposed.  If  one  has  been  unfortunate  enough  to  receive  in- 
jury and  tuberculous  inoculation  is  feared,  the  best  thing  to 

185 


do  is  to  let  the  wound  bleed  freely,  wash  it  thoroughly  with 
water  that  has  been  boiled,  with  a  five  per  cent  solution  of 
carbolic  acid,  or  with  pure  alcohol;  dress  the  wound  with  a 
clean  rag  dipped  in  any  of  these  liquids,  and  seek  as  soon  as 
possible  the  advice  of  a  physician. 

I  have  thus  far  only  spoken  of  tuberculosis  which  manifests 
itself  in  the  pulmonary  form — that  is  to  say,  consumption  of 
the  lungs,  of  intestinal  tuberculosis — that  is  to  say,  consump- 
tion of  the  bowels,  and  tuberculosis  of  the  skin,  or  lupus.  But 
you  must  know  that  every  organ  in  the  body — such  as  the 
throat,  the  bones,  and  the  covering  of  the  brain  and  spinal 
column — is  also  not  infrequently  invaded  by  the  tubercle 
bacillus.  In  the  last  form  the  disease  is  technically  called 
tuberculosis  meningitis. 

NATURAL   RESISTANCE   OF   THE    HEALTHY   INDIVIDUAL 

After  all  that  you  have  heard  so  far  of  the  contagiousness, 
or  rather  the  communicability  of  tuberculosis,  and  consump- 
tion in  particular,  I  do  not  wish  you  to  think  that  a  breath  in 
the  atmosphere  accidentally  laden  with  bacilli  would  certainly 
render  a  healthy  individual  consumptive,  or  that  by  a  sv/allow 
of  tuberculous  milk,  or  a  little  injury  from  a  broken  cuspidor, 
one  must  necessarily  become  tuberculous.  The  secretions  of 
our  nasal  cavities,  doubtlessly  also  the  blood,  and  the  secretions 
of  the  stomach  of  the  healthy  individual,  have  bactericidal 
properties — that  is  to  say,  they  kill  the  dangerous  germs  before 
they  have  a  chance  to  do  harm.  Therefore,  the  healthy  man 
and  woman  should  not  have  an  exaggerated  fear  of  tubercu- 
losis, but  they  should,  nevertheless,  not  recklessly  expose 
themselves  to  the  danger  of  infection. 

But  who  are  the  individuals  who  must  be  particularly  careful 

so  as  not  to  be  attacked  by  the  almost  ever  present  tubercle 

bacillus? 

PREDISPOSITION 

There  are  four  classes:  First,  those  who  have  a  hereditary 
predisposition    to    consumption ;    secondly,    those    who    have 

186 


weakened  their  system  and  thus  predisposed  themselves  to 
consumption  by  the  intemperate  use  of  alcoholic  beverages, 
by  a  dissipated  life,  by  excesses  of  all  kinds,  etc.  ;  thirdly,  those 
whose  constitution  has  been  weakened  through  disease — for 
example,  pneumonia,  typhoid  fever,  small-pox,  measles,  whoop- 
ing-cough, syphilis,  influenza,  etc.  ;  fourthly,  those  whose  oc- 
cupations, trades,  or  professions,  such  as  printing,  hat-making, 
tailoring,  weaving,  and  all  occupations  where  the  worker  is 
much  exposed  to  the  inhalation  of  various  kinds  of  dust,  have 
rendered  them  particularly  liable  to  consumption. 

HEREDITARY   CONSUMPTION 

Before  I  proceed  to  give  you  a  few  of  the  essential  points 
how  to  overcome  such  a  predisposition  to  consumption,  let  me 
answer  the  question:  "What  about  those  who  have  a  so-called 
hereditary  consumption?  "  Permit  me  to  say  that  the  popular 
notion  concerning  hereditary  consumption  is  in  my  humble 
opinion  absolutely  erroneous.  Consumption  has  perhaps  never 
been  inherited  either  from  the  father  or  the  mother,  but  the 
child  has  usually  been  infected  by  its  well-meaning  but  ignorant 
consumptive  parents  after  birth.  The  mother  has  kissed  the 
child,  taken  it  into  her  bed,  alloAved  it  to  use  the  same  spoons 
and  utensils  which  she  has  used  herself,  and  thus  unconsciously 
has  conveyed  the  disease  to  her  infant.  Through  kissing  and 
caressing  a  consumptive  father,  the  child  may  also  be  infected ; 
or  again,  either  the  one  or  the  other  parent  may  have  been 
careless  with  their  expectoration,  may  have  spat  on  the  floor 
where  the  child  plays.  It  must  be  obvious  to  any  thinking  in- 
dividual that  if  such  uncleanly  habits  of  the  father  or  mother 
prevail  the  healthy-born  child  is  not  liable  to  remain  healthy 
long. 

I  have  said  that  consumption  is  not  hereditary,  and  children 
born  of  consumptive  parents  need  not  necessarily  contract  the 
disease.  I  myself  have  seen  children  of  a  consumptive  parent 
grow  up  to  be  strong  men  and  women.  But  their  parents 
were  not  only  careful,  clean,  and  conscientious;  they  were  also 

187 


aware  that,  while  they  did  not  transmit  consumption  to  their 
children,  they  have  transmitted  to  them  a  tendency,  or  predis- 
position, to  this  disease.  This  hereditary  predisposition  is, 
however,  a  condition  which  can  be  overcome  by  judicious 
training,  proper  food,  plenty  of  outdoor  exercises,  and  the 
avoidance  of  all  excesses.  Every  predisposed  individual 
should  dress  sensibly  and  according  to  the  season.  Never 
should  they  wear  garments  which  restrict  circulation  or  hinder 
the  free  physiological  function  of  the  chest  or  abdomen. 
Tightly  laced  corsets,  tight  neckwear,  tight  shoes,  are  all  per- 
nicious and  particularly  dangerous  to  the  individual  predis- 
posed to  tuberculosis. 

ALCOHOLISM 

A  predisposition,  whether  inherited  or  acquired,  may  be 
explained  as  a  peculiar  weakened  state  of  the  system  which 
offers  a  favorable  soil  for  the  growth  and  multiplication  of  the 
germs  of  consumption.  I  have  already  said  what  should  be 
the  duty  of  the  parents  if  they  are  themselves  consumptive 
and  fear  to  have  transmitted  to  their  offspring  a  predisposition 
to  the  disease.  Concerning  alcoholism  and  other  intemperate 
habits,  which  are  so  often  the  forerunners  of  consumption,  I 
desire  to  speak  plainly.  I  do  not  wish  to  appear  to  you  as 
a  temperance  lecturer,  condemning  all  and  everything  which 
does  not  subscribe  to  the  doctrines  of  the  temperance  party. 
I  consider  alcohol  a  medicine,  at  times  indispensable  in  the 
treatment  of  certain  diseases ;  but  liquor  as  a  beverage  is  never 
useful  and  nearly  always  harmful.  Alcoholism  must  be  con- 
sidered the  greatest  enemy  of  the  welfare  of  a  nation,  the  most 
frequent  destroyer  of  family  happiness,  the  cause  of  the  ruin 
of  mind,  body,  and  soul;  and  certainly  the  most  active  co- 
operator  of  the  deadly  tubercle  bacillus. 

To  combat  alcoholism  (drunkenness  or  intemperance),  educa- 
tion above  all  is  required.  Extreme  prosecution  and  fanatical 
laws  will  do  little  good.  From  early  childhood  the  dangers  of 
intemperance  and  its  fearful  consequences  should  be  taught. 

188 


In  schools  and  at  home  the  drunkard  should  be  pictured  as 
the  most  unhappy  of  all  mortals.  While  the  very  moderate 
use  of  feeble  alcoholic  drinks,  such  as  light  beers,  may  be  con- 
sidered as  harmless  to  adults  when  taken  with  their  meals, 
alcohol  should  never  be  given  to  children,  even  in  the  smallest 
quantities.  In  families  in  which  there  is  a  fear  of  hereditary 
transmission  of  the  desire  for  strong  drink,  even  the  mildest 
alcoholic  drinks  should  be  absolutely  avoided.  It  would  also 
be  best  if  all  people  so  predisposed,  or  who  may  have  acquired 
only  the  occasional  desire  for  drink,  would  never  smoke,  for 
experience  has  taught  that  attacks  of  dipsomania  (periodical 
sprees)  are  often  caused  by  an  excessive  use  of  tobacco.  The 
young  man  starting  out  in  life  should  take  with  him  the  moral 
training  which  will  enable  him  to  be  a  gentleman,  and  be  con- 
sidered a  polite  gentleman,  though  he  absolutely  refuses  ever 
to  enter  a  liquor  saloon  in  order  to  treat  or  be  treated  to  drink. 
It  is  this  treating  habit — alas !  so  prevalent  in  our  American 
society — which  has  ruined  many  a  young  man  and  made  him 
a  moral  and  physical  wreck.  The  creation  of  tea  and  coffee 
houses,  where  warm,  non-alcoholic  drinks,  including  bouillon, 
are  sold  in  winter  and  cool  ones  in  summer,  is  to  be  encour- 
aged. It  would  be  of  additional  advantage  if  some  of  these 
houses  could  also  ofTer  healthful  amusements  for  old  and 
young.  Temperance  societies,  which  through  tactful  and  in- 
telligent propaganda  help  to  combat  the  fearful  evil  of  alcohol- 
ism, should  receive  encouragement  from  everybody. 

There  is  another  point  in  regard  to  alcohol  and  tuberculosis 
I  wish  to  emphasize,  and  that  is  the  idea  that  alcohol  is  a 
remedy  or  even  a  specific  remedy  for  consumption.  There 
has  never  been  a  greater  mistake  made.  Alcohol  has  never 
cured  and  never  will  cure  tuberculosis.  It  will  either  prevent 
or  retard  recovery.  It  is  like  a  two-edged  weapon :  on  one 
side  it  poisons  the  system,  and  on  the  other  side  it  ruins  the 
stomach  and  thus  prevents  this  organ  from  properly  digesting 
the  necessary  food.  Truly  pathetic  are  the  results  of  this 
erroneous  doctrine  in  the  families  of  the  poor,  where,  instead 
of  procuring  good  nourishment  for  the  invalid,  liquor  has  been 

189 


bought  in  far  too  large  quantities,  so  that  often  there  was  not 
enough  money  left  for  food  for  the  sufferer  nor  for  the  other 
members  of  the  family. 

DISEASES   AND    OCCUPATIONS   WHICH    PREDISPOSE   TO 
CONSUMPTION 

The  individual  enfeebled  by  disease,  such  as  typhoid  fever, 
grip,  etc.,  should  lead  a  particularly  careful  life  and  avoid 
crowded  meeting-places  and  all  localities  where  the  air  is 
vitiated  and  where  he  is  in  danger  of  coming  in  contact  with 
careless  or  ignorant  individuals  who  expectorate  everywhere. 
Men  who  have  a  trade,  such  as  printers,  tailors,  bookkeepers, 
or  other  workers  whose  occupations  are  more  or  less  predis- 
posing to  tuberculosis,  can  render  their  work  relatively  health- 
ful by  leading  a  sober  life  and,  when  not  at  work,  spending  as 
much  time  as  possible  in  the  open  air,  by  breathing  deeply  and 
keeping  the  body  in  a  thoroughly  good  condition  through 
regular  bathing  and  judicious  exercise. 

THE  CURABILITY  AND  MODERN  METHODS  OF  TREATMENT  OF 

CONSUMPTION 

I  have  taken  for  the  title  of  my  address  to-night  "The 
Duties  of  the  Individual  and  the  Government  in  the  Combat 
of  Tuberculosis,"  and  I  believe  I  have  said  all  I  could  in  the 
brief  space  of  time  allotted  to  me  of  the  duties  of  the  con- 
sumptive, of  those  living  with  him,  of  those  who  are  in  fear 
of  becoming  consumptive,  and  of  the  parents  who  may  have 
transmitted  to  their  children  a  predisposition  to  the  disease. 
The  duty  of  the  individual  who  is  not  included  in  these  four 
classes  is  to  make  himself  acquainted  with  the  facts  stated. 
Every  one,  whether  he  is  consumptive,  or  lives  with  consump- 
tives, or  has  nothing  whatsoever  to  do  with  consumptives, 
should  know  the  few  principal  sources  for  the  propagation  of 
the  disease  and  the  means  to  combat  them.  It  should  be 
known  to  every  one  that  consumption  is  an  infectious,  com- 

190 


municable,  preventable,  and  curable  disease,  and  that  in  the 
early  stages  the  cure  is  often  accomplished  as  many  as  seventy- 
five  to  eighty-five  times  out  of  a  hundred.  What  is  most  in- 
teresting to  know  is  that  this  cure  can  not  only  be  accomplished 
in  California,  or  Colorado,  but  also  in  our  own  home  climate; 
not,  however,  by  quacks  and  patent  medicines,  but  by  the 
scientific  and  judicious  use  of  fresh  air,  sunshine,  water,  abun- 
dant and  good  food  (milk,  eggs,  meat,  vegetables,  fruit),  and 
the  help  of  certain  medicinal  substances  when  the  just-men- 
tioned hygienic  and  dietetic  means  do  not  suffice  in  themselves 
to  combat  the  disease. 

The  thorough  and  constant  supervision  of  the  pulmonary 
invalid,  the  immediate  intervention  when  new  symptoms  mani- 
fest themselves  or  old  ones  become  aggravated  or  do  not  dis- 
appear rapidly  enough,  the  prescribing  of  proper  food  and 
drink,  can  only  be  done  by  the  thoroughly  trained  physician, 
either  in  the  home  of  the  patient  or  a  properly  conducted 
sanatorium. 

Before  proceeding  to  point  out  to  some  individuals  their 
special  duties  in  the  combat  of  tuberculosis,  I  would  like  to 
say  a  word  which  applies  to  all.  On  every  one  with  the  know- 
ledge of  the  prevention  of  consumption,  knowledge  which  he 
may  have  possessed  already  or  which  I  may  have  been  fortunate 
enough  to  convey  to  him,  I  think  it  my  duty  to  impress  the 
fact  that  he  can  do  something  toward  the  combat  of  the 
disease. 

THE  DUTIES  OF  THE  INDIVIDUAL  CITIZEN 

If  you  are  in  the  presence  of  a  consumptive  who  is  not  yet 
under  medical  care,  teach  him  what  you  know  of  the  preven- 
tion of  the  disease  and  advise  him  to  seek  the  counsel  of  a 
competent  physician.  If  he  is  too  poor  to  pay  for  a  consulta- 
tion, and  too  proud  to  ask  it  for  nothing,  tell  him  to  apply  to 
the  health  department,  which  will  send  one  of  its  physicians 
without  cost.  No  tuberculous  invalid,  no  matter  in  what 
stage  of  the  disease,  whether  living  in  a  palace  or  in  the  poorest 
tenement  house,  should  be  without  a  medical  adviser.      If  you 

191 


meet  a  consumptive  who  is  ignorant  of  the  precautions  he 
should  take,  do  not  shun  him  hke  a  leper,  but  treat  him  with 
kindness,  and  convince  him  that  whatever  he  does  to  prevent 
the  spread  of  the  disease  among  others  will  also  improve  his 
own  condition  and  increase  the  chances  of  his  recovery.  Let 
me  tell  you  that  a  clean,  conscientious  consumptive  is  as  safe 
a  person  to  associate  with  as  anybody.  If  in  your  daily  life 
you  can  influence  others  to  make  themselves  familiar  with  the 
necessary  knowledge  of  the  prevention  of  tuberculosis,  do  so ! 
If  through  your  influence,  your  words,  and  example  you  can 
combat  the  fearful  curse  of  our  nation — alcoholism — I  beseech 
you,  do  your  duty. 

Some  individuals  have,  by  virtue  of  their  calling,  a  special 
duty  to  perform  in  the  combat  of  tuberculosis.  Of  these  I 
mention,  first,  the  teachers  of  the  public  schools,  the  clergymen, 
the  editors  of  the  public  press,  employers  and  philanthropists. 

THE   DUTIES   OF   THE   TEACHER 

The  teachers  of  our  public  schools  should  not  only  be  familiar 
with  the  ordinary  methods  of  preventing  the  spread  of  the  dis- 
ease, preach  and  practise  in  their  classrooms  ample  ventilation  ; 
but  they  should  also  be  familiar  with  the  general  appearance 
of  the  tuberculous  child,  so  that  they  may  call  the  attention 
of  the  school  physician  or  the  parents  to  the  condition  of  the 
pupil.  It  should  be  known  that  bone  and  joint  tuberculosis 
is  most  frequently  manifested  in  childhood.  The  early  symp- 
toms of  tuberculosis  of  the  bones  and  joints  show  themselves 
in  the  lameness  and  easy  tiring  of  the  arms  or  legs  affected. 
If  the  spinal  column  is  affected,  the  symptoms  will  depend 
upon  the  location  of  the  vertebra  which  is  attacked  by  the 
disease.  Scrofulosis,  which  is  only  a  milder  form  of  tubercu- 
losis, and  which  is  even  more  frequent  than  bone  tuberculosis 
in  children,  is  easily  recognized.  The  scrofulous  child  is  usu- 
ally pale,  with  flabby  skin  and  muscles.  The  glands  around 
the  neck  are  swollen,  and  skin  disease,  sore  eyes,  and  running 
ears  are  frequent  symptoms.     The  little  patient  usually  mani- 

192 


fests  a  phlegmatic  condition,  but  we  may  also  find  some  that 
are  nervous  and  irritable.  The  latter  often  have  a  peculiarly 
white,  delicate  skin,  which  makes  the  veins  visible.  Fever 
may  be  observed  in  some  children.  In  view  of  the  happily 
very  curable  nature  of  scrofulous  affections,  the  importance  of 
the  early  recognition  and  of  the  timely  and  judicious  treatment 
is,  of  course,  self-evident.  This  scrofulous  condition  may  be 
either  inherited  or  acquired.  The  hereditary  type  comes  from 
parents  who  are  scrofulous,  tuberculous,  or  syphilitic.  It  has 
also  been  proved  that  when  one  or  both  of  the  parents  were 
alcoholics,  that  is  to  say,  addicted  to  the  chronic  use  of  intoxi- 
cants, their  offspring  have  become  scrofulous. 

All  this  shows  how  dangerous  it  is  for  weakly  and  sickly 
persons,  or  those  afflicted  with  any  of  the  above-mentioned 
diseases,  to  marry  and  have  children  before  being  completely 
restored  to  health.  We  wish  to  state  again  that  all  these  dis- 
eases can  be  cured  by  timely  medical  treatment.  To  be  cured 
from  alcoholism,  the  physician's  help  is  not  always  necessary. 
In  most  cases  it  requires  only  the  earnest  and  honest  endeavor 
to  abstain. 

The  principals  of  schools  should  make  it  their  duty  to  in- 
corporate in  the  curriculum  of  all  classes  gymnastics  and  out- 
door exercises  and  play.  The  mental  development  of  our 
children,  valuable  as  it  is,  should  never  be  pushed  to  the  detri- 
ment of  their  physical  development  and  well-being. 

THE  DUTIES  OF  THE  CLERGYMAN 

The  clergymen,  too,  should  inculcate  these  ideas  into  the 
minds  of  the  people  under  their  charge;  and  they  should,  too, 
feel  pride  in  having  their  churches  hygienically  constructed  and 
v/ell  ventilated.  Fixed  carpets  should  not  be  used  in  places  of 
worship  where  so  many  people  congregate.  Catholic  priests 
in  charge  of  large  congregations  may  do  well  to  follow  the  ex- 
ample of  the  great  Roman  divine,  the  Bishop  of  Fano  in  Italy. 
In  a  circular  recently  issued  by  him,  he  asks  the  priests  of  his 
diocese  to  comply  with  the  following  rules: 

193 


"(i)  In  every  church,  the  floor  must  be  regularly  cleaned 
with  sawdust,  saturated  with  a  strong  sublimate  solution. 
This  thorough  cleaning  should  take  place  particularly  after 
holidays  when  great  masses  of  people  have  visited  the  church. 

"(2)  Every  week  all  ordinary  chairs  and  confessional  chairs 
must  be  thoroughly  cleaned  with  moist  rags. 

"(3)  The  grate  of  the  confessional  chairs  must  be  washed 
every  week  with  lye  and  then  polished." 

It  might  be  of  advantage  if  such  articles  of  adoration  as 
crosses,  statues,  or,  as  in  Greek  churches,  pictures,  which  are 
often  kissed  by  devout  Catholics,  be  included  in  the  periodic 
disinfection.  Kissing  the  Bible  when  taking  an  oath  should  be 
discouraged  by  jurists  and  divines. 

Ministers  of  all  denominations  should  consider  it  beneath 
their  dignity  to  allow  their  names  to  be  used  to  advertise  patent 
medicines  and  other  secret  remedies.  I  am  convinced  that  if 
they  were  aware  of  the  fact  that  many  of  the  advertised  patent 
remedies  contain  as  much  as  thirty  and  forty  per  cent  of  alco- 
hol and  often  other  dangerous  ingredients,  they  would  refrain 
from  indorsing  the  use  of  medicines  of  whose  composition 
they  have  not  the  least  idea.  Neither  should  religious  news- 
papers lend  their  columns  to  the  advertisement  of  nostrums 
and  patented  remedies  of  all  sorts.  It  is  to  be  regretted  that 
patent  medicines  are  also  not  infrequently  recommended  by 
statesmen  and  legislators.  Their  personal  indorsement  of  this 
or  that  secret  remedy,  given  without  forethought  and  perhaps 
even  with  good  intentions,  has  often  done  irreparable  harm  to 
the  sufferers. 

THE   DUTIES    OF   THE   PUBLIC   PRESS 

Of  the  duties  of  the  public  press  in  this  fight  against  the 
"great  white  plague,"  the  m.ost  formidable  disease  of  the 
masses,  I  cannot  speak  earnestly  enough.  Our  daily  and 
weekly  papers  have  already  done  much  good  in  disseminating 
knowledge  regarding  the  prevention  of  consumption.  By  con- 
tinuing to  spread  the  literature  of  the  various  associations  and 

194 


committees  on  the  prevention  of  tuberculosis  as  a  disease  of 
the  masses,  they  do  perhaps  more  than  any  other  agent. 

UNSCRUPULOUS  QUACKS  AND  THEIR  METHODS  OF  ADVERTIS- 
ING SO-CALLED  INFALLIBLE  CONSUMPTION  CURES 

Unfortunately,  the  public  press  serves  also  for  the  advertis- 
ing of  the  many  "absolutely  sure  consumption  cures,"  which 
are  from  time  to  time  put  on  the  market  by  unscrupulous 
quacks.  I'am  nevertheless  sanguine  enough  to  hope  that  in 
time  the  better  class  of  newspapers  will,  in  the  interest  of  the 
community  at  large,  no  longer  extend  the  hospitality  of  their 
columns  to  such  dangerous  advertising  matter,  especially  when 
it  is  protested  against  by  the  intelligent  reader.  How  many 
poor  consumptives  have  lost  their  last  little  reserve  fund  by 
giving  everything  they  had  for  a  dozen  bottles  of  the  "sure 
and  quick  cure,"  only  those  who  come  much  in  contact  with 
them  know.  How  unscrupulous  some  of  these  charlatans  are  in 
their  method  of  procuring  certificates  of  cure,  which  they  then 
publish  as  bait  to  the  unfortunate  help-seeking  sufferer,  is 
something  which  can  hardly  be  believed.  Let  me  tell  you  of 
one  instance :  A  poor  woman  in  the  last  stages  of  consumption 
came  to  me  seeking  advice.  When  asked  for  the  name  of  her 
former  medical  attendant,  she  confessed  that  she  had  been 
treated  for  a  number  of  weeks  by  a  quack  concern,  and  now, 
her  m.eans  being  exhausted,  she  was  made  to  understand  that 
they  would  not  continue  to  treat  her  unless  she  would  give 
them  a  certified  testimonial  that  she  had  been  thoroughly 
cured  of  her  disease,  which  had  been  pronounced  an  advanced 
case  of  consumption  by  prominent  physicians.  This  poor 
sufferer  had  not  derived  any  benefit  whatsoever  from  the  treat- 
ment, and  as  a  result  her  conscience  would  not  permit  her  to 
become  a  partner  to  such  a  fraudulent  procedure. 

Some  of  these  unscrupulous  concerns  resort  to  absolute  fraud 
to  beguile  the  public  by  using  the  name  of  the  great  scientist 
and  benefactor.  Prof.  Robert  Koch,  of  Berlin,  as  though  he 
were  associated   with  them  in  their  business  and  treatment. 

195 


They  advertise  his  picture  beside  that  of  an  individual  with  a 
similar  name,  and  are  heading  their  advertisements  as  "Pro- 
fessor Robert  Koch's  Cure."  While  the  medical  profession  at 
large  was,  of  course,  aware  of  this  evident  fraud,  the  public  did 
not  seem  to  be,  and  in  order  to  be  able  to  give  an  official  de- 
nial of  any  such  connection,  a  member  of  the  Committee  on 
the  Prevention  of  Tuberculosis  of  the  Charity  Organization  So- 
ciety of  New  York  City  wrote  to  Prof.  Robert  Koch  of  Berlin, 
Germany.  The  professor's  answer  was  a  lengthy  one  and  full 
of  indignation,  and  I  will  give  you  only  the  substance  of  it. 
He  says  that  the  alleged  "lung  cure  "  of  Dr.  Edward  Koch,  or 
under  whatever  name  this  system  of  treatment  may  be  pre- 
sented to  the  American  public,  is  a  very  base  fraud,  and  that 
he,  Geheimrath  Professor  Dr.  Robert  Koch,  has  no  relations 
whatsoever  with  Dr.  Edward  Koch,  with  any  other  individual 
who  may  be  connected  with  this  concern,  nor  with  any  of  its 
methods  of  treatment ;  neither  has  he  ever  had  any  relations 
with  the  same.  He  hopes  that  the  Committee  on  the  Preven- 
tion of  Tuberculosis  may  be  successful  in  putting  an  end  to  this 
base  and  fraudulent  concern.  This  is  to  be  particularly  desired 
in  the  interest  of  the  many  poor  consumptives  who  have  been 
deceived  by  the  use  of  his  name  in  connection  with  the  so- 
called  Koch's  Consumption  and  Asthma  Cure. 

There  are  numerous  other  concerns  which  put  their  secret 
consumption  remedies  on  the  market  and  resort  to  all  sorts  of 
illegitimate  means  to  make  people  believe  that  their  "cures  " 
are  endorsed  by  the  profession.  Some  claim  to  have  the 
endorsement  of  the  British  Congress  on  Tuberculosis,  others 
to  be  members  of  that  congress;  some  even  resort  to  most 
cunning  means  to  make  it  appear  that  members  of  the  Tuber- 
culosis Committee  of  the  New  York  Charity  Organization 
Society  endorse  their  treatment.  These  remedies,  when  not 
harmful  concoctions,  are  sometimes  commonplace  medicines 
prescribed  daily  by  the  profession.  One  firm  puts  up  the  pre- 
scription for  a  tonic  given  by  a  certain  Vienna  physician,  a 
former  assistant  to  a  polyclinic  (dispensary).  The  drug  firm 
calls  this  doctor  ' '  the  great  Vienna  Professor. ' '     An  individual 

196 


alleged  to  have  been  cured  from  consumption  by  "the  Pro- 
fessor," with  the  aid  of  the  remedy  now  put  up  by  this  firm, 
is  exhibited  in  the  drug  store  as  a  living  testimony  of  the  great 
value  of  the  anti-consumption  remedy  for  sale  there. 

The  misuse  of  the  name  of  the  Committee  on  the  Prevention 
of  Tuberculosis  and  of  some  of  its  members  has  become  so  in- 
tolerable that  the  following  resolutions  were  adopted  recently 
by  the  committee,  and  the  lay  press  has  been  requested  to 
give  them  the  largest  possible  publicity : 

"Whereas,  It  has  come  to  the  knowledge  of  the  Committee 
on  Tuberculosis  of  the  Charity  Organization  Society  that  many 
so-called  specific  medicines  and  special  methods  of  cure  for 
tuberculosis  have  been  and  are  being  exploited  and  widely  ad- 
vertised, and 

"Whereas,  The  advertisements  of  some  of  these  cures  have 
made  such  reference  to  the  Tuberculosis  Committee  of  the 
Charity  Organization  Society,  or  to  some  of  its  members,  as 
to  create  the  inference  that  this  committee,  or  its  members, 
recommend  or  advocate  the  use  of  many  such  so-called  spe- 
cifics or  special  methods  of  cure  for  pulmonary  tuberculosis, 
or  consumption ;  and 

"Whereas,  There  is  no  specific  medicine  for  this  disease 
known,  and  the  so-called  cures  and  specifics  and  special  methods 
of  treatment  widely  advertised  in  the  daily  papers  are  in 
the  opinion  of  the  committee  without  special  value,  and  do 
not  at  all  justify  the  extravagant  claims  made  for  them,  and 
serve  chiefly  to  enrich  the  promoters  at  the  expense  of  the 
poor  and  frequently  ignorant  or  credulous  consumptives ; 
therefore, 

'* Resolved,  That  a  public  announcement  be  made  that  it  is 
the  unanimous  opinion  of  the  members  of  this  committee  that 
there  exists  no  specific  medicine  for  the  treatment  of  pulmo- 
nary tuberculosis,  and  that  no  cure  can  be  expected  from  any 
kind  of  medicine  or  method  except  the  regularly  accepted 
treatment,  which  relies  mainly  upon  pure  air  and  nourishing 
food." 

197 


VALUE  OF  EDUCATING  THE  PUBLIC 

To  break  the  nefarious  trade  of  the  man  who  deals  in  "sure 
and  infallible  "  consumption  remedies,  to  stop  the  practice  of 
the  man  or  woman  who  claims  to  be  able  to  diagnose  and  treat 
consumption  by  letter,  the  Christian  scientists,  the  faith  curists, 
who  ridicule  preventive  measures  and  the  laws  of  cleanliness 
and  hygiene — which  are  the  laws  of  God — but  who,  as  a  token 
of  faith,  demand  their  fees  in  advance ;  we  have  but  one 
weapon,  and  that  is  education — education  by  a  conscientious 
press,  the  clergyman,  and  the  teacher. 

THE  DUTIES  OF  EMPLOYERS 

Factories,  workshops,  stores,  offices,  etc.,  should  be  sani- 
tarily constructed  and  well  ventilated ;  but  besides  this  there 
are  other  things  which  the  employer  can  do  in  the  combat  of 
tuberculosis.  In  factories,  workshops,  stores,  ofifices,  etc., 
there  should  always  be  a  sufficient  number  of  spittoons,  pref- 
erably elevated  and  of  unbreakable  material.  Wherever  such 
precautions  are  taken  and  some  conspicuous  signs,  forbidding 
expectorating  on  the  floor,  put  up,  and  if  necessary,  making  it 
punishable  by  law,  promiscuous  spitting  will  soon  cease,  and 
an  important  point  in  the  combat  of  tuberculosis  will  be 
gained. 

All  employees,  men  and  women,  of  whatever  class,  should 
be  allowed  ample  and  regular  time  for  their  meals,  which 
should  never  be  taken  in  the  workshops.  Lastly,  employees 
should  not  be  overworked.  There  should  be  reasonable  hours 
for  all,  so  that  the  laborer  may  enjoy  the  bodily  and  mental 
rest  which  is  essential  to  the  preservation  of  health.  The 
germs  of  any  disease,  but  particularly  those  of  tuberculosis, 
will  always  find  a  more  congenial  soil  for  development  in  an 
overworked  and  enfeebled  system.  Child-labor,  that  is  to  say, 
the  employment  of  children  under  fourteen  years  of  age,  in 
factories,  workshops,  mines,  etc.,  should  be  prohibited  by  law. 
The  child  is  more  susceptible  to  tuberculosis  than  the  adult, 

198 


especially  when  its  delicate  growing  organism  is  subject  to 
continued  physical  strain.  That  there  are  still  sections  in  our 
country  where  child-labor  is  permitted  to  exist,  is  one  of  the 
saddest  and  most  disgraceful  blots  upon  the  fair  name  of  our 
nation. 

THE  DUTIES  OF  THE  PHILANTHROPIST 

It  is  hardly  fair  to  speak  of  the  duty  of  the  rich  as  philan- 
thropists, for  philanthropy  is  a  voluntary  act,  and  the  rich  man 
cannot  be  compelled  to  give  some  of  his  wealth  to  his  less  for- 
tunate fellow-men.  Still  less  have  we  a  right  to  dictate  to  a 
millionaire  how  to  dispose  of  his  wealth  though  he  may  be 
philanthropically  inclined.  This  country  has,  nevertheless,  a 
right  to  be  proud  of  many  of  its  rich  men  and  women,  and  I 
am  the  last  to  underestimate  the  fortunes  which  have  been 
given  to  the  various  educational  and  religious  institutions  by 
our  Carnegies,  Rockefellers,  Vanderbilts,  Morgans,  Piersons, 
Schiffs,  our  Helen  Goulds,  Phoebe  Hearsts,  Emmons  Blaines, 
etc.,  but  it  is  natural  that  those  of  us  familiar  with  the  needs 
of  the  consumptive  poor  in  this  country  should  look  for  help 
in  solving  this  difficult  tuberculosis  problem  to  the  large-hearted 
American  men  and  women  who  make  such  noble  use  of  their 
wealth.  There  are  now,  perhaps,  plenty  of  libraries  and  col- 
leges, and  even  general  hospitals,  everywhere;  but  there  is  a 
scarcity  of  public  baths,  which  should,  at  a  moderate  price,  be 
at  the  disposal  of  the  people  every  day,  winter  and  summer, 
and  for  some  hours  in  the  evening.  There  is  a  scarcity  of 
decently  kept  places  of  amusement,  open  all  the  year,  where 
the  laborer  and  his  family  may  spend  a  pleasant  Sunday  after- 
noon and  partake  of  non-alcoholic  drinks.  There  is  a  scarcity 
of  hospital  and  sanatorium  facilities  for  thousands  of  poor  con- 
sumptives who  could  be  cured  if  only  taken  care  of  in  time. 
Sanatoria  for  consumptive  adults,  as  well  as  seaside  sanatoria 
for  scrofulous  and  tuberculous  children,  are  a  crying  and  urgent 
need  for  the  majority  of  our  large  American  cities.  The  more 
consumptives  we  cure  the  more  bread-winners  we  create,  and 
the  fewer  people  will  become  burdens  to  the  communities.     As 

199 


the  conditions  are  now,  in  most  of  our  cities  and  towns,  the 
majority  of  consumptives  are  doomed  to  a  certain  and  linger- 
ing death ;  and  if  they  are  careless  or  ignorant  of  the  necessary 
precautions  they  will  infect  some  of  their  own  kin  and  neighbors. 

There  are  from  ten  to  fifteen  thousand  consumptive  poor 
in  New  York  City,  and  there  is  hardly  hospital  and  sana- 
torium accommodation  for  one  thousand.  The  remainder  are 
not  treated  at  all,  or  receive  what  treatment  is  possible  in  the 
homes  of  the  poor.  Recent  statistics,  compiled  by  the  depart- 
ment of  health  of  the  city  of  New  York,  show  that  during  the 
past  year  1,750  consumptives,  who  were  finally  received  and 
have  died  in  the  public  hospitals,  had  been  homeless.  They 
had  slept  in  cheap  lodging-houses,  hallways,  or  wherever  they 
could  find  shelter  for  the  night.  Thirty-seven  of  them  were 
found  dead  in  such  places.  What  do  these  many  homeless 
cases  mean  when  viewed  as  sources  of  infection?  This  must 
give  food  for  thought  to  statesman,  sanitarian,  and  philan- 
thropist alike. 

Would  that  I  could  take  some  of  our  philanthropic  friends 
to  our  densely  crowded  tenement  districts  and  show  them 
there  the  suffering  of  mind  and  body  of  the  poor  consumptive, 
who  must  die,  not  because  his  disease  was  incurable,  but  be- 
cause there  was  no  place  to  cure  it.  I  am  convinced  that  if 
our  generous  and  wealthy  fellow-citizens  would  but  see  for 
themselves  these  conditions,  instead  of  more  libraries,  uni- 
versities, and  colleges,  we  would  soon  have  better  tenements, 
more  playgrounds  and  parks  for  children,  and  an  abundance 
of  sanatoria  and  hospitals  for  our  consumptive  poor. 

A  few  more  gifts,  such  as  recently  bestowed  by  Charles  M. 
Schwab  in  the  shape  of  an  extensive  and  beautiful  playground 
to  the  children  of  New  York,  and  by  Henry  Phipps,  in  the 
shape  of  a  tuberculosis  institute  for  Philadelphia's  consumptive 
poor,  will  work  wonders  in  the  reduction  of  the  mortality  from 
tuberculosis. 

Concerning  the  recent  magnificent  donation  of  Mr.  Rocke- 
feller of  seven  million  dollars  to  search  for  a  specific  medicine 
to  cure  consumption,  I  could  wish  that  the  University,  repre- 

200 


senting  the  city  of  Chicago,  which  is  the  recipient  of  the  gift, 
were  allowed  to  use  the  greater  portion  of  these  millions  for 
the  purchase  of  the  worst  tenements  in  that  city  and  the  erec- 
tion of  model  houses  for  the  laborer  in  their  stead ;  for  the 
establishment  of  a  few  playgrounds;  for  public  baths,  and 
last,  but  not  least,  for  the  establishment  and  maintenance  of 
sanatoria  for  the  poor  and  moderately  poor  consumptives. 

THE  DUTIES  OF  THE  MUNICIPAL  GOVERNMENT 

It  remains  only  for  me  now  to  speak  of  the  duties  of  the 
government.  First,  what  is  the  duty  of  the  local  or  municipal 
government  in  the  combat  of  tuberculosis  as  a  disease  of  the 
masses? 

Each  city  should  have  an  efficient  committee  on  tuberculosis 
composed  of  a  number  of  general  practitioners,  health  officers, 
and  trained  charity  workers.  This  commission  should  have 
its  offices  in  a  building  connected  with  a  special  dispensary  for 
tuberculous  patients.  Each  case  applying  should  be  carefully 
examined  for  the  following  purposes : 

(i)  To  determine  the  applicant's  condition  by  medical  ex- 
amination. 

(2)  To  visit  his  home  if  he  has  been  found  tuberculous,  and 
to  institute  such  hygienic  measures  as  seem  necessary  (distri- 
bution of  pocket  spittoons,  disinfectants,  etc.,  gratuitously  if 
the  patient  is  poor). 

(3)  To  examine  the  other  members  of  the  family,  in  order 
to  find  out  if  any  of  them  have  also  contracted  the  disease, 
and,  if  so,  to  counsel  proper  treatment. 

(4)  To  report  in  full  to  the  sanitary  authorities  concerning 
the  condition  of  the  patient's  dwelling.  Its  renovation  or 
even  destruction  may  be  imperative  when  it  is  evident  that 
tuberculosis  has  become  "endemic  "  there,  owing  to  the  con- 
dition of  the  soil  or  to  other  sanitary  defects. 

(5)  To  determine  the  financial  condition,  whether  the  patient 
is  or  is  not  able  to  pay,  and  whether  or  not,  by  his  being  taken 
to  an  institution,  the  family  will  become  destitute. 

301 


If  the  latter  should  be  the  case,  it  would  be  necessary  for 
provision  to  be  made  in  some  way  for  the  family.  In  many 
cases  a  letter  of  inquiry  sent  to  the  former  medical  attendant 
of  the  patient  would  materially  aid  in  the  work  of  the  investi- 
gating committee. 

Any  individual  should  have  the  right  to  present  himself  for 
examination,  and  every  physician  should  be  at  liberty  to 
recommend  any  person  for  examination  to  the  board  of  his 
precinct  or  district. 

Every  city  should,  of  course,  have  an  efficient  health  depart- 
ment, a  building  department,  tenement-house  commission, 
street-cleaning  department,  and  a  board  of  education,  all  of 
them  combining  to  render  the  city  as  sanitary  as  possible 
and  thus  combating  centres  of  contagion  of  tuberculosis 
and  other  diseases,  keeping  our  streets  as  free  from  dust, 
filth,  and  smoke  as  possible,  preventing  the  construction  of 
unsanitary,  unsafe  dwellings  and  the  overcrowding  in  homes, 
sweat-shops,  and  factories,  and  making  of  the  public  schools 
where  our  children  dwell  so  many  hours  models  of  perfect 
ventilation  and  places  for  true  intellectual  and  physical  de- 
velopment, thus  furthering  the  physical  and  moral  welfare  of 
the  entire  community. 

THE  DUTIES  OF  THE  STATE  GOVERNMENT 

Our  state  legislators  should  do  their  utmost  to  enact  such  laws 
as  will  secure  always  proper  ventilation  and  light  in  public  and 
private  buildings.  How  necessary  such  laws  are,  you  will  be- 
lieve when  I  tell  you  that  there  are  in  Manhattan  over  200,000 
and  in  Brooklyn  over  125,000  dark  interior  rooms  without  a 
window  of  any  kind,  and  having  no  means  of  light  and  ventila- 
tion. Such  attempts  as  are  now  before  the  New  York  legisla- 
ture to  cripple  the  work  of  the  tenem.ent-house  commission  and 
allow  greedy  contractors  to  continue  to  erect  tenements  with- 
out light  and  air,  veritable  breeding-places  of  consumption, 
should  receive  the  just  condemnation  of  every  citizen  in  the 
land. 

203 


PREVENTION  OF  TUBERCULOSIS  IN  CATTLE 

Another  feature  in  the  combat  of  consumption,  which  to  my 
mind  has  been  somewhat  neglected,  is  the  prevention  of  tuber- 
culosis among  animals,  for  notwithstanding  Professor  Koch's 
recent  declaration  at  the  tuberculosis  congress  in  London, 
there  is  still  too  much  evidence  of  the  possibility  of  the  trans- 
mission of  tuberculosis  from  the  bovine  to  the  human  race. 
If  I  am  rightly  informed,  there  is  an  amendment  proposed  by 
the  Live  Stock  Association  which  would  enable  them  to  keep 
cattle  in  transit  for  forty  consecutive  hours  without  food  or 
water.  From  an  unsigned  letter  to  the  editor  of  the  Evening 
Post,  of  January  29,  I  quote  as  follows:  "The  law  as  it  now 
stands — depriving  the  unfortunate  animals  of  those  necessities 
for  twenty-eight  consecutive  hours,  through  summer's  torrid 
heat  and  winter's  chill — is  inhuman  enough.  To  extend  this 
limit  of  endurance  would,  indeed,  stamp  us  as  a  barbarous, 
disgraced  nation,  not  only  in  the  eyes  of  the  world,  but  what 
is  worse,  in  our  own  estimation.  The  greed  which  would 
tempt  a  $600,000,000  organization  to  impose  such  a  national 
inhuman  stigma  should  call  for  loudest  condemnation  from 
the  government,  from  the  press,  and  from  individuals." 

Let  me  add  that  we  should  not  forget  that  close  proximity 
of  diseased  and  healthy  individuals,  lack  of  air  and  food,  and 
other  privations,  are  causes  of  the  propagation  of  tuberculosis, 
not  only  among  men  but  among  animals  as  well,  and  that  con- 
sumptive cattle  may  give  consumption  to  man. 

THE  DUTIES  OF  THE  FEDERAL  GOVERNMENT 

State  boards  of  health  should  receive  ample  appropriation  to 
•  combat  tuberculosis  among  men  and  animals  and  be  helpful  in 
creating  state  sanatoria  and  agricultural  colonies  for  consump- 
tive adults,  and  seaside  sanatoria  for  scrofulous  and  tuberculous 
children ;  also  special  hospitals  and  tuberculosis  dispensaries ; 
and  lastly,  the  United  States  Government  should,  after  the 
example  of  Great  Britain,  France,  and  Germany,  not  only  have 

303 


a  ministry  of  public  health,  but  also  a  special  commission,  ap- 
pointed by  the  President  of  the  United  States,  composed  of 
expert  sanitarians,  physicians,  and  veterinarians,  who  should 
unite  with  the  state  and  municipal  sanitary  authorities  of  the 
country  in  the  combat  of  tuberculosis  in  all  its  forms  among 
man  and  beast. 

CONCLUSION 

If  every  individual  in  his  respective  sphere,  and  the  local, 
state,  and  Federal  governments,  would  do  his  full  duty  in 
the  combat  of  this  fearful  scourge  of  mankind,  so  justly  called 
by  Oliver  Wendell  Holmes  "the  great  white  plague,"  I  am 
convinced  that  before  many  decades  tuberculosis  would  be 
eradicated  from  our  midst,  and  the  United  States  would  have 
the  honor  of  being  the  first  among  the  nations  of  the  earth  to 
have  accomplished  this  great  and  glorious  work. 


204 


Appendix  8     ■ 
TUBERCULOSIS  AND  CHILDREN 

By  a.  JACOBI,   M.D.    . 


205 


TUBERCULOSIS   AND   CHILDREN 

Tuberculosis  kills  as  many  people,  old  and  young,  as 
diphtheria,  croup,  whooping-cough,  scarlatina,  measles,  and 
typhoid  fever  taken  together.  In  many  of  our  cities,  princi- 
pally New  York,  measures  have  been  taken  to  reduce  the 
fatality  of  the  latter.  Until  a  few  brief  years  ago  none  was 
taken,  however,  to  reduce  the  mortality  from  tuberculosis. 
But  the  attention,  both  of  the  general  public  and  the  authori- 
ties, has  now  been  directed  to  the  means  of  its  alleviation  and 
future  extinction.  Movements  have  been  organized  to  spread 
the  knowledge  of  its  causes,  prevention,  and  cure. 

In  writing  of  tuberculosis  as  it  appears  in  the  young,  I  need 
only  refer  to  the  fact  that  it  is  an  infectious  disease  due  to  the 
presence  of  a  specific  microbe  called  tubercle  bacillus,  is  a  dis- 
ease which  runs  its  course  acutely  in  a  few  weeks  or  chronically 
in  dozens  of  years,  and  is  liable  either  to  remain  dormant  and 
the  patient  to  get  practically  well,  or  to  lead  to  a  speedy  death. 
It  is  located  in,  or  takes  its  origin  from,  one  of  a  number  of 
different  organs.  It  may  run  its  full  course  to  recovery  or  to 
death  in  a  single  organ,  or  may  be  traced  to  a  number  of  organs 
at  the  same  time.  It  is  best  known  among  us  in  the  lungs, 
under  the  name  of  pulmonary  consumption.  This  is  the  usual 
form  it  takes  in  the  adult.  It  is  almost  always  transmitted  by 
the  inhalation  of  bacilli  which  are  contained  either  in  the  moist 
air  surrounding  the  coughing  consumptive,  or  in  the  dry  dust 
of  rooms,  halls,  and  streets. 

Pulmonary  consumption  is  a  frequent  disease  in  all  countries, 
and  in  most  nations  of  Europe  one-third  of  the  working  popu- 

207 


lation  between  their  fifteenth  and  sixtieth  years  die  of  it.  The 
same  form  of  pulmonary  tuberculosis  is  not  frequent  in  infancy, 
but  is  quite  frequent  in  childhood ;  the  tubercular  infection 
has,  however,  many  more  sources  and  locations  in  the  young 
than  in  the  old.  Some  of  the  forms  in  which  tuberculosis 
makes  its  appearance  in  the  young  I  shall  merely  mention,  in 
order  to  recall  to  your  minds  such  instances  of  the  disease  as 
you  have  seen  but  perhaps  not  always  recognized,  and  to  pre- 
sent many  forms  of  it  that  frequently  sail  under  a  false  flag.  I 
shall  be  brief,  for  my  object  is  rather  to  point  out  some  of  the 
many  ways  in  which  tuberculosis  may  invade  the  young,  and 
those  methods  by  which  it  may  be  prevented. 

A  frequent  place  in  which  tuberculosis  may  be  found  is  the 
bone.  Here,  in  the  infant  and  child,  it  is  very  frequent.  Go 
to  any  dispensary  or  college  clinic ;  go  to  the  Hospital  for  the 
Ruptured  and  Crippled  in  Forty-second  Street,  New  York;  to 
the  Orthopaedic  Hospital  and  Dispensary  in  East  Fifty-ninth 
Street,  or  to  the  Tarrytown  State  institution.  The  bone  ab- 
scesses of  the  fingers,  the  feet,  the  knees,  the  hip,  the  spine, 
with  its  Pott's  disease  and  life-long  deformities  in  those  who 
survive,  are  mostly  of  tuberculous  origin.  Another  form  of 
tuberculosis  may  be  studied  when  it  develops  in  the  peritoneum 
of  the  young.  I  say  of  the  young,  for  in  the  adult  this  form 
is  rare.  The  child  of  from  three  to  eight  or  more  years,  either 
pale  and  haggard  or  apparently  robust,  may  complain  of 
abdominal  pain,  which  is  either  spontaneous,  or  elicited  by 
pressure.  Among  the  main  symptoms  is  the  swelling  of  the 
abdomen,  which  is  caused  by  local  dropsy.  In  the  well-to-do 
classes,  this  peritoneal  tuberculosis  is  very  apt  to  heal  spon- 
taneously or  under  medicinal  treatment,  or  after  a  slight  opera- 
tion. In  the  poor  quarters  recovery  is  possible,  but  very  slow; 
the  majority  of  patients  will  finally  succumb  under  the  in- 
fluence of  generalized  tuberculosis.  This  simple  fact  is  one  of 
the  thousand  which  teaches  that  mutual  responsibility,  that 
equality,  fraternity,  and  solidarity  are  still  far  away,  if  not 
Utopian,  and  that  human  society  is  not  yet  humane. 

Another  grave  form,  also  almost  exclusively  met  with  in  the 

208 


young,  is  meningeal  tuberculosis.  Tubercular  tumors,  some- 
times found  in  the  brain — mostly  of  the  young — are  always 
fatal.  Tuberculous  inflammation  of  the  brain  membranes  is  a 
frequent  disease.  Up  to  the  second  year,  its  symptoms  are 
attended  with  great  vehemence,  high  temperature,  early  con- 
vulsions, and  rapid  death.  Between  the  second  and  ninth 
year,  the  symptoms  are  as  follows :  Pallor,  changed  tempera- 
ment, morose  or  irritable,  bad  headaches,  slow  and  irregular 
pulse,  vomiting,  slow  increase  of  the  body  temperature,  dilated 
pupils,  some  form  of  convulsion,  constipation  and  diminished 
urine,  congestion  of  head  and  face,  high  temperatures,  and 
death.  Many  know  the  disease  on  account  of  its  frequency. 
The  almost  universal  result  is  death  after  from  three  to  five 
weeks.  There  are  only  a  few  authenticated  cases  of  recovery. 
My  friend.  Professor  Biedert  of  Hagenau  diagnosticated  a  case 
which  got  well.  The  child  died  after  a  few  years  of  an  acute 
disease,  an  autopsy  was  made,  and  the  traces  of  the  old  tuber- 
cular meningitis  were  found.  This  is  a  clear  case,  very  ex- 
ceptional, on  the  part  of  a  reliable  diagnostician,  of  recovery. 
But  would  the  recovery  have  been  permanent?  If  the  child 
had  not  died  in  young  years,  would  the  physician  still  speak 
of  a  complete  recovery?  Nobody  can  tell.  Listen  to  a  single 
instance  among  my  observations.  About  forty  years  ago  I 
diagnosticated  a  case  of  tubercular  meningitis  in  a  boy  of  three 
years.  He  got  well ;  that  is,  he  did  not  die.  For  some  years 
there  were  no  particular  complaints.  But  the  child's  temper 
was  changed,  he  was  bad,  became  more  irritable,  vehement, 
violent,  and  sometimes  dangerous.  He  was  a  slow  learner 
except  of  the  use  of  his  muscle.  He  remained  wayward,  with 
sudden  outbreaks  of  malice,  irresponsible,  unreliable.  When 
he  reached  his  twentieth  year,  he  also  reached  the  insane 
asylum ;  where  he  still  is,  to  remain  as  long  as  he  lives.  We 
called  that  a  recovery  with  which  we  were  proudly  delighted. 
Why  do  I  write  of  such  a  case?  To  impress  you  with  the  fact 
that  tuberculosis  of  the  brain  and  its  meninges  is  frequent  in 
infancy  and  childhood,  that  it  is  almost  always  fatal,  and  that 
even  apparent  escapes  are  not  necessarily   recoveries.      And 

209 


finally,  as  there  is  practically  no  escape  from  the  established 
disease,  in  this  form  at  least,  the  duty  is  to  look,  where  there 
is  no  cure,  for  preventives.     And  that  is  possible. 

You  will  have  noticed  that  all  these  forms  of  tuberculosis 
are  mostly  the  prerogatives  of  the  young.  Diseases  of  an  irri- 
tative, congestive,  or  inflammatory  nature,  no  matter  whether 
primary  or  secondary,  are  mostly  found  in  those  young  organs 
which  are  in  a  condition  of  physiological  growth.  The  bones 
and  the  brain  belong  to  that  class.  Their  development  in 
early  years  is  very  rapid,  and  the  natural  congestion  required 
for  normal  growth  is  liable  to  become  morbid.  That  is  why 
an  over-exerted  organ  at  any  age  is  liable  to  become  diseased ; 
for  instance,  the  muscle  in  athletes,  the  heart  in  runners.  One 
of  the  most  active  systems  in  the  very  young  is  the  lymph 
system,  consisting  as  it  does  of  millions  of  smaller  and  larger 
vessels  extending  through  the  whole  body  and  hundreds  of 
lymph  bodies  located  about  the  neck,  in  the  armpit,  in  the 
groin,  in  the  chest,  in  the  gut  and  abdomen,  all  of  which  are 
active  in  conducting  the  chyle  to  the  blood,  and  increasing  and 
changing  the  number  of  white  blood  corpuscles.  These  lymph- 
bodies,  falsely  called  glands,  are  mostly  observed  about  the 
neck.  They  make  their  appearance  in  slight  irritation  of  the 
mucous  membrane  of  the  nose,  throat,  or  mouth,  and  are  liable 
to  disappear  when  that  irritation  is  but  temporary.  They  per- 
sist, and  are  mostly  known  as  hard  nodes  or  more  or  less  de- 
forming scars,  under  the  denomination  of  "scrofulous  glands," 
about  the  neck  and  other  external  and  internal  parts.  These 
glands  are  not  always  tuberculous,  but  they  may  and  fre- 
quently do  become  so.  Tuberculosis  of  the  glands  of  the  neck 
may  terminate  in  abscesses ;  of  those  in  the  chest,  in  chronic 
bronchitis  and  pulmonary  tuberculosis;  of  the  abdomen,  in 
tubercular  ulcerations  of  the  bowels  and  in  peritoneal  tubercu- 
losis, which  I  characterized  above.  Under  certain  circum- 
stances even  a  mild  congestive  or  inflammatory  swelling  of  the 
lymph  bodies  or  glands  may  become  tubercular.  That  is  why 
it  is  our  object  to  study  these  circumstances,  and  to  control 
and  avoid  them. 

210 


Direct  heredity  of  tuberculosis  is  very  rare,  and  as  a  statistical 
factor  hardly  counts.  In  fifty  years  of  medical  practice,  I  have 
seen  a  single  unmistakable  case ;  in  medical  literature  there  are 
only  a  few  dozen,  in  man  and  animal  together.  When  there 
are  many  cases  of  tuberculosis  in  a  family,  there  is  no  heredi- 
tary transmission  of  the  disease  but  rather  a  heredity  of  dis- 
position, consisting  in  a  defective  structure  of  the  tissues  in 
general,  combined  with  the  frequent  opportunity  of  communi- 
cating the  disease.  When  a  baby  takes  tuberculosis  while 
lying  in  the  lap  of  its  mother,  it  succumbs  not  to  heredity,  but 
possibly,  to  a  slight  extent,  to  the  influence  of  a  tubercular 
breast  milk,  more  certainly  to  a  feeble  structure  of  all  its 
tissues — the  mucous  membranes  of  its  digestive  and  breathing 
apparatus  in  particular, — and  principally  to  the  inhalation  of 
bacilli  from  the  air  into  which  the  mother  coughs  and  from  the 
dust  of  the  room  in  which  dry  bacilli  congregate.  It  is  very 
probable  that  not  many  babies  of  a  consumptive  mother  would 
perish  from  tuberculosis  if  it  were  possible  to  take  them  to  the 
mother  for  the  purpose  of  nursing  only.  Bad  cases  of  ma- 
ternal tuberculosis  might  even  demand  that  the  mother  should 
wear  a  veil  during  nursing,  in  order  to  prevent  the  flying  drops  of 
expectoration  from  entering  the  air  and  the  lungs  of  the  infant. 

What  is  the  cause  of  the  disposition  of  which  I  have  spoken? 
I  have  mentioned  the  great  disposition  of  young  children  to 
diseases  of  the  mucous  m.embranes.  All  young  structures  are 
less  firm  and  less  organized  than  those  of  the  adult.  As  a 
matter  of  common  experience,  I  mention  only  the  frequency 
in  the  young  of  diseases  of  the  nose  and  throat.  Catarrhs  are 
frequent ;  diphtheria  is  almost  exclusively  a  disease  of  child- 
hood. The  majority  of  diseases  and  deaths  in  the  first  year  of 
life  are  digestive;  after  that,  respiratory.  As  I  have  said,  ab- 
sorption is  more  rapid  in  the  young,  and  that  is  why  prevention 
may  be  so  powerful,  while  the  cure  of  fully  established  tuber- 
culosis is  frequently  a  failure.  Can  this  disposition  to  disease, 
this  weakness  of  the  structures,  particularly  of  the  mucous 
membrane,  be  overcome,  and  tuberculosis  arising  from  that 
source  be  avoided? 

211 


Much  has  been  said  about  hardening.  What  does  it  mean? 
Nothing  but  this :  that  the  resistance  of  the  child  to  the  effect 
of  external  influences  should  be  strengthened.  Is  there  a  uni- 
form method  applicable  to  every  child,  no  matter  of  what  age 
or  constitution?  Certainly  not.  But  there  is  one  object  which 
should  be  accomplished  in  every  infant  and  child ;  viz.,  the  in- 
vigoration  of  external  circulation.  The  surface  of  a  child  from 
two  to  ten  years  measures  from  three  to  ten  square  feet.  In 
and  under  that  surface  there  is  a  lake  of  blood.  In  vigorous 
health  this  blood  is  in  constant  and  rapid  circulation ;  within 
two  minutes  it  enters  and  leaves  the  surface,  comes  from  and 
leaves  the  centre  of  circulation,  the  heart.  Slow  circulation  in 
the  surface  retards  the  flow  of  blood  in  the  whole  body,  and 
impairs  the  nutrition  of  the  heart  and  every  organ,  causing 
congestion  and  insufiflcient  function,  and  disease.  Rapid  cir- 
culation in  and  under  the  skin,  causing  rapid  circulation 
everywhere,  propels  the  totality  of  the  blood  in  the  child's 
body  (from  two  to  six  pounds  according  to  age — from  two 
to  twelve  years)  into  and  through  the  lungs,  in  which  the 
contact  with  and  the  absorption  of  the  oxygen  of  the  atmos- 
phere takes  place.  Now  the  best  stimulant  of  the  circu- 
lation in  general  is,  besides  muscular  exertion  (exercise), 
the  stimulation  of  the  skin  by  cold  water  and  friction.  A 
child  of  two  or  three  years  should  have  a  daily  cold  wash, 
either  after  a  v/arm  bath,  or  standing  in  warm  water  which 
covers  the  feet,  or  lying  on  the  attendant's  lap,  or  on  a  mat- 
tress. A  brisk  rubbing  with  a  wet  towel,  one  or  two  minutes, 
and  with  a  dry  towel  until  the  surface  is  dry  and  warm,  is 
sufficient.  Older  children  may  have  a  wet  sponge  squeezed 
out  over  them,  this  procedure  being  followed  by  the  same 
effective  friction ;  or  they  may  plunge  into  cold  water,  in  the 
winter  a  single  moment,  in  the  summer  several  minutes. 
While  in  any  bath,  the  skin  should  be  thoroughly  rubbed. 

This  rule  must  not  become  a  routine  applicable  to  every  in- 
dividual. Cold  water  and  friction  require  a  healthy  heart  and 
a  certain  degree  of  strength.  They  only  facilitate  the  reaction 
that  should  be  looked  for  in  every  instance.     The  same  healthy 

213 


child,  when  taken  sick  or  when  convalescent  from  a  disease, 
lacks  the  necessary  vigor,  and  the  routine  must  be  interrupted. 
A  child,  under  size  and  under  weight,  requires  warmer  water 
and  friction.  That  is  why  a  newly  born  baby  or  an  infant  of 
less  than  one  or  two  years  should  be  spared  a  low  temperature. 
That  is  why  also  a  child  whose  feet,  after  a  bath  or  washing, 
do  not  get  so  warm  as  the  rest  of  the  body  should  be  rubbed 
down  not  with  cold  but  with  warm  water,  or  with  a  mixture 
of  alcohol  and  warm  water,  until  the  constitution  is  gradually 
improved  and  fortified. 

These  rules  appear  simple;  indeed,  are  simple.  That  is  why 
the  discussions  of  medical  and  lay  journals  met  with  lately 
are  out  of  place.  There  are  those  who,  with  great  earnestness, 
condemn  hardening  because  they  see  colds,  chills,  pneumonia, 
and  what  not  after  cold-water  treatment.  If  two  do  the  same 
thing,  it  is  not  the  same.  It  is  with  hygiene  as  it  is  with  diet. 
The  very  young,  the  older,  the  healthy,  and  the  sick,  the  ro- 
bust, and  the  feeble,  must  not  be  treated  nor  fed  according  to 
ironclad  rules.  It  has  appeared  to  me  that  a  few  good  rules, 
understood  and  intelligently  applied,  are  a  safer  guidance  than 
the  forceful  exhibitions  of  inexperienced  medical  juvenility  as 
lately  displayed  in  the  magazines. 

How  is  it  that  tubercle  bacilli  enter  into  the  system?  We 
are  surrounded  by  them ;  there  are  very  few  of  us  whose  noses 
and  throats  and  mouths  are  not  often  inhabited  by  the  microbes 
of  tuberculosis,  of  diphtheria,  probably  of  typhoid,  of  pneu- 
monia. Why  do  they  usually  not  harm  us,  and  under  what 
unfavorable  circumstances  do  they  enter  our  circulation?  The 
answer  is  this :  As  long  as  the  mucous  membranes  on  which 
these  unwelcome  but  ubiquitous  guests  are  deposited  are  in  a 
normal  condition,  these  latter  do  not  enter  beyond  the  vesti- 
bule. It  is  very  improbable  that  their  mere  presence  changes 
the  actual  condition  of  their  resting  place.  But  rapid  changes 
of  the  surface  are  common  in  the  slightest  alterations  caused, 
for  instance,  by  a  common  cold.  A  draught  over  your  feet 
that  makes  you  sneeze  and  shiver,  that  congests  the  mucous 
membranes  and  starts  a  sudden  secretion  that  reminds  you  of 

213 


the  waters  of  Babylon,  disintegrates  the  fine  epithelial  cover- 
ing. As  soon  as  such  a  surface  injury  occurs,  a  simple  throat 
catarrh  may  change  into  a  diphtheria,  the  very  vulnerable  ton- 
sils may  admit  into  the  circulation  the  microbes  of  rheumatism 
or  of  scarlet  fever,  a  single  bronchial  catarrh  will  allow  the 
poisonous  pneumococcus  to  light  up  a  pneumonia  that  may 
carry  you  off  in  three  or  six  days.  All  this  depends  on  a 
trifling  occurrence,  a  draught  between  improperly  opened  win- 
dows, mainly  in  cold,  wet  weather ;  a  wet  stocking  that  is 
allowed  to  dry  on  your  foot ;  an  open  trolley-car  door  while 
you  are  in  perspiration.  Tuberculosis  may  get  in  through  any 
defect  of  the  surface.  It  may  enter  the  brain  through  the  sore 
adenoids  and  mucous  membrane  of  the  nose ;  for  indeed  the 
direct  lymph  communication  between  the  two  surfaces  of  the 
skull,  one  inside  the  skull  and  the  other  in  the  nose  and  throat, 
is  a  very  intimate  one.  I  am  certain,  for  example,  that  you 
have  heard  of  instances  in  which  the  character  and  the  mental 
capacities  of  a  child  were  rapidly  changed  by  the  cutting  out 
of  enlarged  tonsils  and  the  scraping  off  of  adenoids.  There  is 
no  better  proof  of  the  intimate  connection  between  different 
layers  of  circulation ;  in  these  cases  between  the  external  and 
the  internal  surfaces  of  the  skull. 

Tuberculosis  of  the  tonsil  itself  is  a  very  rare  disease,  but 
there  is  no  reason  why  bacilli  should  not  enter  the  circulation 
through  its  sore  surface.  Tuberculosis  of  the  mouth  is  not 
quite  so  rare  as  it  appeared  to  be  formerly,  for  many  a  case 
that  was  called  a  cancer  of  the  mouth  turned  out  to  be  tuber- 
cular ulceration.  The  gullet  and  the  stomach  are  not  known 
as  the  points  of  invasion  for  tuberculosis,  but  the  lower  part 
of  the  intestinal  tract  certainly  acts  as  a  source  of  infection. 
Here  we  touch  the  question  of  the  influence  on  the  gut  of  sub- 
stances that  have  been  swallowed.  What  is  it  that  is  swallowed? 
Either  food  and  drink,  or  the  secretion  of  the  nose  and  mouth, 
and  the  expectoration  from  the  lungs  during  coughing. 

First. — Food  and  drink.  It  has  been  assumed  sometimes 
that  the  eating  of  meat  from  tuberculous  cattle  transmits 
tuberculosis.     That  is  a  mistake,  and  the  destruction  of  tuber- 

214 


culous  carcasses  for  that  reason  uncalled  for.  There  are  no 
tubercle  bacilli  in  the  muscle — that  is,  the  flesh;  if  there  were, 
meat  is  not  taken  raw,  and  boiling  kills  the  bacilli.  Drink, 
through  which  tuberculosis  could  be  transmitted,  means  milk 
of  tuberculous  cows.  Is  it  so  very  dangerous  as  it  has  been 
believed  to  be?  It  can  be  made  uninjurious — that  should 
never  be  forgotten — by  boiling  the  milk  a  few  minutes,  or 
Pasteurizing  it  at  167  degrees  Fahrenheit  ten  minutes.  That 
will  kill  bacilli ;  and  a  dead  bacillus  is  as  harmless  as  the  dead 
Indian  of  a  certain  grim  soldier.  But  milk  is  not  always  boiled 
even  for  infants ;  not  even  in  big  cities  in  which  it  takes 
milk  from  four  to  thirty  hours  to  get  into  the  hands  of  the 
consumer, — a  delay  which  is  always  injurious.  Why  is  it  not 
boiled?  The  reasons  are  ignorance,  indolence,  or,  in  some 
cases,  the  necessities  caused  by  certain  illnesses.  Infantile 
scurvy,  for  instance — that  peculiar  disease  with  hemorrhages  on 
the  long  bones,  blue  spots  here  and  there,  swelling  and  bleed- 
ing of  the  gums — is  frequently  the  result  of  the  overboiling  of 
milk.  In  these  cases,  raw  milk  should  be  obtained  and,  as  at 
least  two  per  cent,  of  all  dairy  cows  are  tubercular,  infected 
milk  may  get  into  the  bowels  of  the  infant.  In  a  casual  way. 
I  will  just  add  that  milk  may  easily  be  overboiled.  Some 
people  pride  themselves  on  the  thoroughness  with  which  they 
recommend  or  practise  boiling.  But  then  it  is  not  called  boil- 
ing, it  is  called  sterilization,  and  a  foreign  word  of  five  syllables 
is  so  ornamental,  don't  you  know.  Proudly  an  affectionate 
mother  tells  you  she  sterilizes  the  milk  her  baby  is  to  take,  for 
thirty,  forty,  sixty  minutes.  She  would  not  do  less  for  her 
baby,  not  she.  But  she  should  know,  or  learn,  that  what  is 
saved  of  milk  after  forty  minutes'  boiling  is  no  longer  a  healthy 
milk,  and  not  fit  to  keep  her  baby  in  health. 

Is  the  partaking  of  fresh  milk  of  tuberculous  cows  connected 
with  great  danger?  As  long  as  the  bowels  are  in  a  normal 
condition,  the  danger  is  not  great ;  for  the  acid  contained  in 
the  stomach  is  not  kindly  borne  by  bacilli,  and  as  long  as  the 
infant  or  child  does  not  suffer  from  the  remnants  of  former  in- 
flammations and  ulcerations — I  remind  you,  however,  of  the 

215 


many  attacks  of  diarrhoea,  summer  complaint,  etc. — the  bacilli 
are  merely  swept  through  the  intestines  with  the  food  rem- 
nants, and  the  danger  of  intestinal  tuberculosis  is  passed. 
You  may  have  heard,  nevertheless,  that  doctors  disagree  in 
regard  to  the  possibility  or  impossibility  of  transferring  cow 
tuberculosis  to  man,  and  human  tuberculosis  to  cattle.  Nobody 
believes  the  question  entirely  settled,  but  it  is  an  established 
fact  that  the  bacilli  of  every  disease,  tuberculosis,  diphtheria, 
cholera,  or  typhoid  fever,  are  not  always  of  equal  violence, 
and  that  the  differences  of  opinions  and  of  results  depend  fre- 
quently on  the  difference  in  the  poisonous  qualities  of  such  a 
bacillus,  as  is  the  subject  of  momentary  experimentation.'  So 
we  have  to  permit  the  doctors  to  disagree  a  little  longer  on  an 
occasional  point.  There  is  one  point,  however,  on  which  there 
should  be  no  disagreement ;  which  is  this :  The  stomach  and 
intestines  of  the  newly  born  and  the  very  young  infant  are  not 
completed.  Their  epithelial  layer  is  defective,  and  the  younger 
the  infant,  the  greater  is  the  facility  of  microbic  invasion  even 
when  they  are  perfectly  well. 

There  are  many  undoubted  cases  of  feeding  milk  from  tuber- 
culous cows  that  resulted  in  tuberculosis.  My  late  friend, 
Olivier,  of  Paris,  has  the  following  report :  Thirteen  school 
girls  in  a  Paris  boarding-school  were  taken  with  tuberculosis., 
Six  died.  Some  of  them  had  the  disease  first  in  their  bowels. 
The  milk  came  from  a  tuberculous  cow  with  a  badly  affected 
udder.  Johne,  a  great  veterinary  anatomist,  examined  a  cow 
that  had  the  reputation  of  being  the  finest  on  a  farm  until  she 
became  emaciated  and  died.  On  account  of  her  splendid  con- 
dition her  milk  had  been  selected  by  the  farmer  for  his  own 
infant.  The  child  died  of  tuberculosis  at  the  age  of  two  years 
and  a  half.  A  case  like  this  proves,  besides  other  things,  the 
correctness  of  my  teaching  these  more  than  forty  years  that  it 
is  always  safer  to  select  milk  from  a  herd  of  cows  than  from  a 
single  cow  and  thereby  to  dilute  possible  dangers. 

Second. — Expectoration  is  swallowed  and  carried  down  the 
intestinal  tract.  Infants  and  children  never  bring  up  the  re- 
sults  of  a  cough.     Bronchial  catarrh,  pneumonia,   influenza, 

216 


croup  membranes,  tubercular  expectoration,  everything  goes 
down ;  that  is  why  in  doubtful  cases  it  often  takes  days  even 
in  a  hospital  to  secure  mucus  or  pus  enough  for  a  microscopic 
examination.  As  long  as  the  mucous  membranes  of  the  ab- 
dominal contents  are  healthy,  the  poisonous  substances  pass 
through  like  remnants  of  food.  When  they  meet  a  sore  or 
ulcerous  substance,  the  bacilli  have  their  chance  of  settling 
down  and  making  themselves,  at  least,  comfortable.  That 
happens  more  often  in  the  young  than  in  the  old.  For  the 
young  gut  is  more  predisposed  to  absorption,  its  nets  of  blood- 
vessels being  extremely  complex  and  the  lymphoids  and  ducts 
large  and  numerous.  Do  not  forget  in  this  connection,  that 
the  bowels  of  the  young  are  frequently  diseased.  The  large 
majority  of  diseases  and  deaths  in  the  first  year  of  life  is  still 
due  to  the  alimentary  canal ;  chronic  congestion  and  ulcera- 
tion persist  often  for  a  long  period,  and  predispose  to  the 
deposits  of  infectious  microbes. 

What  I  told  you  about  the  frequency  of  tuberculosis  of  the 
peritoneum  at  that  age  should  prove  to  you  the  greater  tend- 
ency of  the  young  gut  to  submit  to  tuberculosis  than  of  the 
old.  But  we  are  always  told,  mainly  by  Koch  and  his  fol- 
lowers, that  the  cases  of  tubercular  infection  thus  caused  are 
only  rare  indeed.  Those  who  are  stricken,  however,  though 
they  be  considered  only  exceptions,  look  at  the  question  from 
their  own  point  of  view ;  if  it  were  your  case  you  could  not 
be  convinced  that  yours  is  no  suffering  for  the  reason  that 
others  escape.  And,  after  all,  the  cases  are  not  rare  by  any 
means;  the  vast  majority  of  tubercular  peritonitis  is  the  result 
of  intestinal  invasion,  and  good  observers,  like  Sill  of  London 
and  Shennan  of  Edinburgh,  assert  that  twenty-eight  or  twenty- 
nine  per  cent,  of  tuberculosis  enters  through  the  bowels. 
Heller  published  the  reports  of  714  autopsies,  140  of  which 
were  made  on  persons  who  had  died  of  tuberculosis.  Among 
these  140  there  were  2  of  the  intestines  and  neighboring  mes- 
enteric glands,  33  of  the  mesenteric  glands,  and  10  more  of 
mesenteric  and  other  glands  ;  altogether  53  out  of  140.  Hanse- 
mann  wrote  quite  lately  an  elaborate  paper  to  show  that  tuber- 

217 


culosis  resulted  very  rarely  indeed  from  feeding.  His  figures, 
however,  are  more  conclusive  than  his  reasoning.  In  the 
autopsies  of  40  children  who  died  of  pulmonary  consumption 
after  swallowing  all  the  expectoration,  he  found  one  with 
tuberculosis  of  the  stomach,  16  of  the  intestines,  which  means 
that  in  nearly  one-half  of  the  cases  the  children  had  undoubt- 
edly had  their  intestines  affected  by  what  they  swallowed. 
Still,  we  cannot  believe  that  milk  from  a  tuberculous  cow  with 
a  tuberculous  udder  is  so  poisonous  as  the  contents  of  a  con- 
sumptive lung  which  are  swallowed,  but  this  is  only  a  matter 
of  degree.  It  is  possible  that  cattle  tuberculosis  may  finally  be 
proved,  though  belonging  to  the  same  class,  to  be  less  poisonous 
than  human  tuberculosis ;  it  may  be  proved  that  the  bacilli  of 
milk,  butter,  and  cheese  are  not  endowed  with  great  virulence ; 
yet,  after  all,  there  are  many  proofs  of  actual  and  possible 
danger  coming  from  tuberculous  milk.  The  production,  trans- 
portation, and  consumption  of  milk  is  not  merely  an  economic 
or  agricultural  problem,  but  a  serious  hygienic  and  sanitary 
question. 

Let  us  consider  a  few  of  the  localities  which,  by  being  kept 
in  a  healthy  condition,  may  be  prevented  from  becoming  an 
inlet  of  tuberculosis. 

A  nasal  catarrh  in  a  child  should  be  attended  to.  Though  it 
last  only  a  few  days,  the  neighboring  lymph-nodes,  "glands," 
about  the  angle  of  the  lower  jaws  begin  to  swell.  What  can 
you  do  for  it?  The  customary  oiling  or  greasing  of  the  back 
of  the  nose?  I  think  it  does  the  mother  more  good  than  the 
baby.  When  there  is  much  discharge,  and  obstruction  of  the 
nose,  difificult  respiration,  an  open  mouth  and  a  dry  tongue, 
the  nose  should  be  gently  irrigated  with  warm  salt  water  at 
ninety  or  ninety-four  degrees,  one-half  teaspoonful  of  salt  to 
one-half  pint  of  water,  not  from  a  dropper,  nor  from  a  spray, 
but  from  one  of  the  many  nasal  glass  cups  in  the  market.  In- 
jection syringes  should  be  used  by  very  careful  persons,  or 
experts,  only — for  forcible  injections  may  injure  the  ear.  If 
you  run  a  teaspoonful  of  the  salt  solution  into  each  nostril,  re- 
peatedly, it  will  reappear  on  the  opposite  side,  or  in  the  throat. 

218 


Gagging  and  swallowing  is  not  harmful.  The  procedure  is  so 
useful  that  numberless  cases  of  glands  around  the  neck  that 
have  lasted  for  weeks,  will  get  well  with  this  gentle  process 
alone,  without  any  medication.  A  nose  kept  clean  wall  also 
be  a  protection  against  the  deposit  of  bacilli  and  the  growth  of 
adenoids.  For  the  normal  soft  lymphatic  tissue  which  belongs 
to  the  posterior  nares  will  grow  when  the  neighboring  circu- 
lation is  impeded,  will  form  adenoids,  and  may  still  be  restored 
when  relieved  by  washing.  A  similar  effect  is  obtained  by 
reducing  the  size  of  enlarged  tonsils.  They  are  frequently 
large  at  birth.  Every  new  cold  adds  to  their  size  and  to  their 
danger,  which  consists  in  the  deposits  of  bacilli  of  all  kinds 
and  the  absorption  of  their  chemical  poisons.  I  find  very  fre- 
quently, however,  that  the  removal  of  enlarged  tonsils  and  the 
scraping  off  of  adenoids  is  not  sufficient — or  apparently  in- 
effectual; if  such  cases  are  studied  it  will  be  found  that  there 
is  a  thickening  and  catarrhal  condition  of  all  the  surrounding 
parts.  The  operation  alone  is  not  suf^cient  unless  it  is  fol- 
lowed by  a  long-continued  course  of  two  or  three  daily  irriga- 
tions as  described. 

The,  mucous  membrane  of  the  mouth  is  very  apt  to  be  in- 
jured; hot  feeding,  clumsy  washing  of  the  little  mouth,  a  de- 
caying tooth,  the  remnants  of  an  inflammation,  blistering  or 
thrush  which  mothers  justly  fear,  should  be  met  with  absolute 
cleanliness.  No  food  should  be  allowed  in  the  mouth  after 
feeding ;  a  few  teaspoonfuls  of  water  after  a  meal ;  early  attend- 
ance on  the  teeth;  in  case  of  catarrh,  the  washing  of  the 
mouth  v/ith  a  teaspoonful  of  boracic  acid  in  a  cup  of  water. 

Frequently  the  catarrh  descends,  or  originates,  in  the  wind- 
pipes or  bronchial  tubes.  Within  a  few  days  of  coughing  and 
feverishness  the  glands  in  the  chest  begin  to  swell ;  they  are 
very  apt  to  become  tuberculous ;  not  to  speak  of  the  numerous 
cases  of  different  forms  of  bronchitis  and  pneumonia  which 
follow  a  common  catarrh,  particularly  in  sickly  children. 
These  things  are  frequently  neglected ;  as  the  sick  are  only 
small,  their  sicknesses  are  deemed  small  to  a  ludicrous  extent. 
Some  thirty  years  ago  a  well-meaning  man  with  a  large  family 

219 


said  to  me:  "Doctor,  you  must  now  and  then  make  a  call.  I 
do  not  mean  to  bother  you  much.  When  there  are  some  such 
trifles  as  sick  children,  I  shall  not  send  but  take  the  doctor 
around  the  corner;  but  you  must  promise  to  come  and  see  us 
when  we  older  people  are  sick."  I  said :  "I  shall  make  a  bar- 
gain with  you.  I  permit  you  to  send  for  me  when  the  children 
are  sick.  When  you  are  sick  yourself,  just  send  for  the'doctor 
around  the  corner,  or  you  may  'cry  for  Castoria. ' 

As  I  said,  there  are  a  great  many  cases  of  inflammation 
whose  development  can  be  prevented ;  and  a  great  many,  like 
those  in  influenza,  in  whooping-cough,  or  in  measles,  which 
are  very  apt  to  become  tubercular,  and  run  off  into  pulmonary 
consumption.  In  all  such  cases,  small  or  big,  apparently 
trifling  or  dangerous,  the  ordinary  person  is  beyond  his  depth. 
This  is  where  a  doctor  comes  in  handy.  I  never  knew  the  best 
one  to  be  too  good  for  a  baby.  In  connection  with  this  a 
warning  may  be  timely.  There  are  a  great  many  diseases 
which  run  a  regular  course,  and  others  in  which  the  duration 
and  course  may  be  modified.  Typhoid  fever,  scarlet  fever, 
measles,  belong  to  the  first  class ;  whooping-cough,  to  the  latter. 
It  has  become  a  fashionably  indolent  habit  to  leave  them 
alone.  If  you  cannot  cure  them,  however,  you  can  modify 
and  shorten  them.  Whooping-cough,  it  is  true,  will  find  its 
natural  termination  in  three  or  four  months  or  more,  but  often 
the  child  finds  its  natural  termination  before  the  three  or  four 
months  are  up.  Every  coughing  spell,  every  day's  illness,  is 
a  source  of  dangers.  Some  of  these  are  convulsions,  bronchitis, 
pneumonia,  tuberculosis.  They  may  occur  during  any  day  or 
week.  If  you  had  an  opportunity  to  cut  the  disease  short  in 
five  or  six  weeks,  every  secondary  complication  that  occurs 
later  is  of  your  making,  and  every  death  is  on  your  soul. 

A  few  words  on  fresh  air. 

Theoretically  everybody  is  convinced  that  the  blood  cannot 
be  freely  aerated,  and  the  health  must  suffer  unless  the  air  we 
inhale  is  pure.  The  young  organism  suffers  in  this  respect 
more  than  the  old,  for  it  requires  more  oxygen  comparatively. 
It  is  impossible  to  go  into  particulars  here,  except  to  say  that 

230 


unless  a  sufficient  supply  of  oxygen  is  kept  up  and  the  per- 
centage of  carbonic  acid  stays  below  seven  per  mille,  and  unless 
direct  injuries  be  kept  out,  health  is  incompatible  with  such 
faulty  conditions.  The  changes  in  the  air  of  our  rooms  which 
we  have  to  fight  constantly  are  as  follows :  It  is  too  dry  under 
the  influence  of  our  heating  apparatus.  Furnaces  and  most 
other  heaters  furnish  a  dry  air  which  changes  the  surface  of  the 
mucous  membranes  in  the  nose,  throat,  and  the  lungs.  There 
is  no  more  voracious  oxygen  eater  than  the  gas  stove.  Car- 
bonoxid  is  the  result  of  imperfect  combustion,  and  a  deadly 
poison ;  so  are  the  chlorine  gas,  the  nitric  and  sulphuric  acids 
contained  in  our  coal  supply.  They  have  even  changed  former 
health  resorts,  such  as  Denver,  on  account  of  the  increase  of 
factory  chimneys,  into  questionable  or  dangerous  localities. 
Add  to  this  the  dust  of  the  houses  and  streets  with  all  it  con- 
tains, particles  of  stone,  metals,  vegetable  remnants  and  mi- 
crobes, and  further  the  poisonous  exhalations  of  the  skin  and 
intestines  of  men  and  animals,  such  as  sulphides, — all  of  this 
locked  up  in  small  rooms  inhabited  by  many  old  and  young — 
thousands  of  these  rooms  in  Greater  New  York  have  no  win- 
dows,— calculate  that  the  majority  of  our  population  live  under 
such  circumstances  and  surroundings,  and  you  will  no  longer 
wonder  why  there  are  so  many  cases  of  catarrh,  bronchitis, 
pneumonia,  infectious  fevers,  and  tuberculosis.  You  will  rather 
be  surprised  that  there  are  so  many  left  with  healthy  organs, 
and  also  that  public  opinion  has  not  progressed  far  enough 
either  to  treat  the  greedy  enemies  of  a  decent  tenement-house 
law  as  criminals  who  should  be  the  execration  of  mankind,  or 
to  send  them  to  Bellevue  for  the  examination  of  their  mental 
condition. 

Why  do  we  send  our  tubercular  patients  to  the  country  and 
see  many  of  them  getting  well?  Because  there  they  have  pure 
air  and  plenty  of  it.  Only  do  not  imagine  that  the  name  of  a 
locality  must  have  a  magic  influence.  What  happens  to  me 
very  often  is  that  a  poor  consumptive  operative  comes  for  ad- 
vice. His  doctor  has  told  him  that  he  is  consumptive,  and 
that  unless  he  goes  to  Sullivan  County,  or  to   Colorado,   at 

221 


once,  he  is  sure  to  die.  This  brutal  notice  is  frequently  given 
to  people  who  cannot  scrape  together  the  travelling  expense. 
But  if  they  could,  what  then?  They  would  live  in  a  small  attic 
on  poor  food  with  no  hope  and  nobody  as  a  support.  There 
is  plenty  of  air,  but  none  for  them.     They  die  the  sooner. 

The  air  in  the  country  is  pure,  and  is  plenty,  not  because, 
as  some  joker  said,  the  farmers  keep  the  vitiated  air  within 
their  own  houses  and  rooms  that  are  never  opened,  but  because 
even  in  crowded  country  communities  the  cubic  space  obtain- 
able to  whomsoever  can  be  on  his  feet,  is  interminable.  That 
is  why  farmers  who  know  how  to  cook  and  to  eat,  and  particu- 
larly farmers'  children,  look  ruddy  and  vigorous,  while  city 
people  and  their  children  are  necessarily  pale  and  anaemic  and 
listless,  and  why  diseases  of  the  mucous  membranes,  finally 
leading  to  tuberculosis,  are  so  frequent  among  our  children 
when  locked  up  in  narrow  city  rooms. 

A  grave  danger  to  adults  and  children,  mainly  the  latter, 
are  our  bedrooms.  Indeed,  my  friend  Biermer,  late  professor 
in  Zurich  and  Breslau,  called  tuberculosis  a  bedroom  disease. 
With  what  right?  A  baby  is  at  least  sixteen  hours  a  day  in 
that  narrow,  confined,  airless,  windowless  bedroom ;  a  child  at 
least  ten  or  fourteen  hours,  the  greater  part  of  its  young  life. 
The  air  is  the  reverse  of  what  it  should  be  to  protect  blood 
formation,  circulation,  and  digestion.  What  can  be  done  to 
improve  it  to  a  certain  extent?  Some  window  should  be  open 
all  night  and  day.  If  there  be  none  in  the  bedroom,  there  is 
one  in  the  adjoining  front  room  or  the  kitchen  at  the  rear. 
Unfortunately  not  always,  for  we  are  still  in  an  era  of  the 
selfish  refusal  on  the  part  of  man  to  be  held  responsible  for  the 
evils  and  ills  of  his  neighbors.  We  are  hardly  entitled  to  call 
ourselves  a  civilized  community  when  fifty  thousand  families 
at  least,  with  three  or  six  children  each,  live  each  in  one  light 
room  and  one  or  two  small  dark  holes.  In  these  holes  they 
breed  tuberculosis.  But  it  is  no  consolation  to  you  that  they 
die  of  it.  Before  they  die  they  infect  their  neighbors;  and 
their  neighbors,  in  the  capacities  of  seamstresses,  servant  girls, 
laundresses,  cooks,  teachers,  infect  you  and  your  children  and 

333 


your  friends'  children.      It  is  not  necessary  to  draw  a  lesson  in 
just  so  many  words. 

Bedrooms  want  air,  air,  air.  Half  an  inch — an  inch  of  open 
space  on  the  top  of  a  window  somewhere  must  be  allowed.  It 
must  be  open  all  night.  That  must  become  a  habit  never  to 
be  relinquished.  It  is  one  that  goes  along  with  a  clean  skin 
and  as  clean  clothing  as  circumstances  permit.  An  open  win- 
dow does  not  mean  draught,  which  should  be  avoided.  It 
can  always  be  avoided,  when  the  fresh  air  comes  from 
one  side  only.  When  the  window  is  too  near  the  bed, 
or  beds,  let  the  immediate  draught  be  provided  against  by 
a  screen,  or,  when  there  is  no  screen,  by  a  blanket  or  a 
sheet  so  fastened  that  it  render  the  same  service.  Now  and 
then  you  will  hear  the  objection,  that  the  little  ones  will 
uncover  themselves  during  their  sleep  and  thus  be  exposed. 
In  hot  air  and  a  teeming  atmosphere  filled  with  improper  gases 
they  will  uncover  themselves,  but  when  the  air  is  cool,  they 
keep  covered.  In  connection  with  all  these  rules  and  advices, 
teachers  could  do  a  great  deal,  provided  they  give  the  matter 
any  thought.  There  are  too  many  who  do  not.  Our  per- 
fectly overcrowded  public  and  normal  schools  are  always  too 
hot.  Windows  are  opened  indiscriminately.  Children  sitting 
under  them  are  directly  exposed.  Thousands  of  New  York 
cases  of  catarrh,  bronchitis,  pneumonia,  and  tuberculosis  could 
be  avoided,  if  a  little  knowledge — that  is  all  that  is  required — 
were  combined  with  a  fair  amount  of  common  sense.  I  say  a 
little  knowledge;  I  am  firmly  convinced  that  the  rules  that 
teachers  should  be  directed  to  communicate  to  their  flock  can 
be  printed  on  eight  or  ten  pages,  or  less. 

The  general  rules  for  the  prevention  of  tuberculosis  are  valid 
for  the  young  as  they  are  for  the  old.  There  must  be  no  spit- 
ting on  the  floor,  nor  in  handkerchiefs  and  towels.  Food  and 
drink  should  be  boiled.  Food  should  be  simple  and  nutritious ; 
milk  and  cereals  should  be  or  are  cheap.  Indiscriminate  kiss- 
ing should  be  stopped. 

A  few  additional  warnings  for  teachers  might  be  as  follows: 

Halls  should  be  nearly  as  warm  as  the  schoolrooms. 

223 


Children  should  not  be  in  the  rooms  during  a  recess. 

Recesses  should  be  longer  than  they  are ;  the  younger  the 
children,  the  longer  should  recesses  be  between  lessons. 

Vacations  should  be  longer.  The  second  Monday  in  Sep- 
tember is  part  of  our  hot  season. 

There  must  be  no  dusting  in  the  presence  of  children ;  in 
fact  the  cleaning  of  the  floors  should  be  no  dry  brooming.  No 
child  should  ever  be  expected  to  help  in  it. 

This  is  not  for  school  buildings  only ;  but  for  apartment  and 
tenement  houses.  There  is  no  greater  danger  to  the  com- 
munity than  the  carpets  in  thousands  of  tenement  houses  that 
are  never  cleaned  and  harbor  the  bacilli  of  tuberculosis  and 
typhoid  and  diphtheria  that  have  accumulated  for  years  and, 
as  no  light  ever  strikes  them,  remain  alive  indefinitely. 


234 


Appendix  9 

THE  CLIMATIC  AND   SANATORIUM 
TREATMENT  OF  CONSUMPTION 

By  henry  p.  LOOMIS,  M.D. 


15 


225 


THE  CLIMATIC   AND  SANATORIUM  TREATMENT 
OF  CONSUMPTION 

There  is  no  problem  of  more  absorbing  interest  to-day  to 
physicians  from  a  medical  and  humanitarian  aspect  or  to  the 
public  from  a  social  and  economic  standpoint,  than  the  com- 
prehensive management  or  care  of  people  suffering  from  con- 
sumption. Any  consideration  bearing  directly  on  this  question 
should  be  inspired  solely  by  its  relation  to  two  central  thoughts : 
the  welfare  of  the  consumptive  class  and  the  permanent  pro- 
tection of  the  community.  The  welfare  of  the  consumptive, 
especially  among  the  poorer  classes,  necessitates  intelligent  aid 
rendered  to  those  in  the  earlier  stages  of  the  disease,  thus 
affording  a  reasonable  prospect  of  successful  cure.  The  interest 
of  the  community  is  in  the  prevention  of  the  spread  of  the  dis- 
ease from  the  sick  to  the  well, — this  to  be  along  the  lines  of 
some  well-directed  and  far-reaching  system  of  education  of  the 
masses  as  to  right  methods  of  living,  the  dangers  of  con- 
tagion, and  the  importance  of  recognizing  and  treating  the  first 
evidences  of  the  disease. 

The  Charity  Organization  Society,  through  its  Committee 
on  Tuberculosis,  is  effectively  working  along  these  lines.  The 
interest  of  the  community  also  demands  the  removal  from  its 
very  midst  of  destitute  invalids  who  constitute  not  only  a  per- 
sonal burden  to  the  family  but  a  menace  to  society  through 
their  ignorance  and  inability  to  observe  certain  well-known 
precautions  against  spreading  the  malady. 

227 


This  latter  problem  must  be  solved  by  municipal  and  state 
aid.  I  have  seen  in  the  last  twenty  years  innumerable  new 
methods  of  treatment  and  cures  for  this  disease  hold  for  a 
time  the  attention  of  the  medical  profession  and  the  people, 
but  they  have  all  disappeared,  and  the  only  method  to-day 
which  has  stood  the  test  of  time  and  which  is  recognized  all 
over  the  world  as  promising  the  best  results,  is  what  is  known 
as  the  climatic  treatment  of  consumption,  that  is,  the  living  in 
a  suitable  climate  and  breathing  pure  air. 

I  can  almost  positively  affirm  that  if  any  one  of  you  here  to- 
night should  develop  consumption  you  would  make  every 
sacrifice  to  leave  New  York  and  go  and  live  in  a  suitable 
climate.  I  notice  that  the  medical  profession  to  a  man  when 
they  become  infected  with  the  disease  follow  this  plan.  To 
illustrate  this,  I  found  on  investigation  that  of  the  forty  phy- 
sicians in  Denver,  thirty  per  cent  had  consumption  when  they 
went  to  Colorado.  Climate,  then,  is  the  only  curative  agent 
which  has  stood  the  test  of  time.  To  the  wealthy  the  change 
to  suitable  surroundings  is  an  easy  matter.  To  those  in  mod- 
erate circumstances  it  is  often  a  burden.  To  the  poor  it  is 
generally  impossible.  To  this  last  class  aid  must  be  given. 
While  climate  far  outweighs  all  other  methods  of  treating  this 
disease  it  is  expensive.  It  is  often  said  that  the  prognosis  of 
consumption  depends  upon  the  purse  of  the  patient.  This  is 
true  only  to  a  certain  extent. 

CLIMATE 

As  the  seeds  of  consumption  come  from  the  air  we  breathe, 
so  in  a  great  measure  its  cure  is  effected  through  the  same 
channel.  I  do  not  believe  with  some  that  there  is  any  specific 
climate  for  consumptives,  nor  do  I  believe  with  others  that  any 
climate  is  good  provided  the  air  is  pure  and  uncontaminated. 
While  climate  is  not  a  specific  it  far  outweighs  all  other  aids 
we  have  in  the  treatment  of  this  disease.  We  all  know  what 
a  tonic  effect  a  change  of  climate  and  surrounding  has  on  us 
when  we  become  run  down  or  tired  out.      We  cannot  say  just 

228 


what  this  effect  is  due  to,  but  we  know  that  we  eat  better, 
sleep  better,  and  more  quickly  regain  our  normal  health  than 
by  any  othef  means.  This  same  tonic  effect  on  the  general 
system  of  the  consumptive  is  apparent,  and  much  more  so  than 
in  one  suffering  from  any  other  disease.  Climate,  then,  holds 
the  first  place  as  an  improver  of  nutrition  ;  besides,  the  pure  air 
breathed  in  has  a  distinct  and  beneficial  effect  on  the  inflamed 
and  diseased  lung,  so  we  have  both  a  general  and  a  local  effect, 
so  to  speak.  It  has  been  found  that  the  more  fresh  and 
bracing  air  consumptives  can  breathe  the  more  they  improve; 
they  are  advised,  therefore,  to  remain  out  of  doors  as  much  as 
possible — eight,  ten,  twelve  hours,  to  sleep  with  their  windows 
open,  and  so  practically  to  breathe  the  pure  air  of  any  particular 
locality  for  the  whole  twenty-four  hours.  I  may  say  that  the 
best  climate  for  a  consumptive  is  the  one  that  will  permit  him 
to  remain  out-doors  more  and  longer  at  a  time  than  anywhere 
else;  as  in  health  not  all  climates  suit  every  individual,  so  the 
consumptive  is  found  to  present  personal  idiosyncrasies ;  but  it 
is  a  safe  rule  to  go  by — to  remember  that  the  kind  of  climate 
in  which  the  person  always  felt  the  best  before  he  contracted 
consumption  will  most  probably  be  the  kind  of  climate  that  will 
ag-ree  with  him  after  he  has  contracted  this  disease.  As  sun- 
shine  is  the  greatest  foe  the  consumption  germ  can  encounter, 
and  direct  sunlight  will  quickly  destroy  the  most  virulent  tu- 
bercle bacilli,  so  that  climate  which  has  the  greater  number 
of  clear,  sunny  days  is  the  climate  in  which  most  consumptives 
do  the  best.  This  is  one  of  the  great  reasons  why  our  northern 
winters  and  springs  are  so  bad  for  consumptives, — this  and  the 
sudden  changes  of  temperature  which  are  of  such  constant 
occurrence.  Places,  no  matter  how  favorably  situated  as  to 
general  climatic  conditions,  may  from  some  local  cause,  such 
as  the  too  close  proximity  of  high  mountains,  liability  to  high 
winds,  or  sudden  changes  of  temperature,  be  rendered  un- 
favorable for  consumptives.  At  one  time  it  was  thought  con- 
sumptives could  hardly  stand  a  cold  climate,  and  I  can  remember 
how  twenty  years  ago  they  were  sent  to  our  Southern  climates, 
such  as  Florida,  especially  to  escape  the  cold.     This  has  all 

239 


changed  now- — and  it  is  a  well-known  fact,  which  has  been  em- 
phasized by  Dr.  Trudeau  in  his  experience  in  the  Adirondacks, 
where  the  temperature  for  much  of  the  time  is  below  zero,  that 
consumptives  always  do  better  in  the  winter  than  in  the  sum- 
mer. Experience  has  proven  that  the  majority  of  people  living 
in  low  altitudes,  or  sea-port  cities,  when  they  contract  con- 
sumption, improve  more  rapidly  if  they  make  a  change  of 
climate  to  inland,  and  to  elevated  regions.  Altitude,  I  believe, 
is  a  very  important  element  in  the  climate  for  a  consumptive. 
It  is  not  necessarily  the  high  altitude  of  five  thousand  feet  of 
Colorado,  but  in  my  experience  most  cases  do  better  at  an  ele- 
vation of  above  twelve  hundred  feet.  I  know  there  are  some 
exceptions,  such  as  when  the  disease  develops  in  those  ad- 
vanced in  years,  in  those  of  unusual  nervous  temperament, 
or  people  in  advanced  stages  of  the  disease.  Another  element 
of  climate  which  experience  has  proven  is  important,  is  dry- 
ness. So  important  do  some  of  the  English  physicians  con- 
sider this  that  they  are  now  sending  their  patients  to  a  health 
resort  recently  established  in  the  desert  about  ten  miles  from 
Cairo.  Here  it  is  so  dry  that  meat  exposed  to  the  air  never 
spoils. 

Wherever  we  find  this  combination  we  may  rest  assured  that 
consumptives  will  do  well,  and  if  not  in  a  too  far  advanced 
stage  of  the  disease,  will  recover.  We  are  fortunate  in  having 
in  America  the  finest  and  best  climate  the  earth  affords — where 
also  may  be  found  the  comforts  of  life  which  are  so  essential 
in  cases  at  all  advanced. 

From  what  I  have  just  said  you  readily  perceive  that  there 
are  three  elements  of  climate  which  are  to-day  most  generally 
believed  to  be  essential  for  people  with  consumption. 

I .  Sunshine  :  The  maximiun  amount  of  clear  days  with  sun- 
shine.— The  conditions  of  high  and  dry  climate  are  best  met  in 
our  country  on  the  elevated  plateaux  of  Colorado,  New  Mexico, 
and  Arizona,  and  at  such  places  as  Denver,  Colorado  Springs, 
El  Paso,  Las  Vegas,  Albuquerque,  New  Mexico,  and  Phoenix 
in  Arizona.  The  conditions  of  moderate  elevation  and  pure 
atmosphere  we  find   in    Asheville,  North   Carolina,  the  Adi- 

330 


rondack  Mountains,  and  at  Sullivan  County  in  our  own 
state,  while  the  soft  and  soothing  influence  of  a  pure  and 
balmy  atmosphere  is  provided  in  lower  California,  in  Aiken, 
and  in  Thomasville,  Georgia,  and  at  Nassau.  It  has  been 
found  that  strong  individuals  in  the  first  early  stages  of  con- 
sumption do  exceedingly  well  in  a  colder  climate,  while  ad- 
vanced and  feeble  persons  improve  in  balmy  and  low-altitude 
situations. 

2.  Altitude. — We  all  know  that  as  we  ascend  there  is  a 
marked  reduction  in  the  pressure  of  the  atmosphere.  This  is 
so  much  so  in  very  high  altitudes  that  it  is  almost  impossible  to 
breathe.  In  high-altitude  health  resorts,  on  account  of  this 
diminution  of  pressure,  greater  work  is  put  upon  the  heart  and 
lungs  so  that  by  the  process  of  rapid  heart  and  lung  action  in- 
creased nutrition  is  brought  to  the  diseased  lung.  Purity  of 
air  really  means  air  free  from  germs.  It  has  been  proven  that 
ten  cubic  meters  of  air  in  New  York  contain,  on  an  average, 
fifty-five  thousand  germs.  It  has  also  been  shown  that  germs 
steadily  diminish  as  the  altitude  increases,  and  at  an  elevation 
of  thirteen  thousand  feet  they  are  no  longer  found  in  any  por- 
tion of  the  globe.  The  danger  of  inhaling  ordinary  germs  is 
that  a  mixed  infection  may  occur,  by  which  is  meant  that  the 
changes  in  the  lungs  caused  by  the  tubercle  bacillus,  the  germ 
of  consumption,  may  be  rendered  much  more  active  by  the 
entrance  of  other  germs. 

3.  Dryness. — Dryness  in  the  air  is  also  an  important  factor 
in  climate.  It  has  been  proven  by  experiments  that  the  con- 
sumption germ  multiplies  very  rapidly  under  moisture,  and  the 
inhaling  of  moist  air  seems  to  have  the  effect  of  stimulating 
their  activity  in  the  lungs. 

It  will  be  readily  seen  by  any  one  who  visits  open  health  re- 
sorts where  a  number  of  consumptives  are  collected  together, 
why  many  of  them  do  not  improve.  The  climate  may  be 
ideal,  and  the  invalids  may  be  having  the  most  nutritious  food, 
and  still  the  general  life  they  lead  does  away  with  all  the 
climatic  advantages.  Late  hours,  excess  in  eating  and  drink- 
ing,  staying  in   closed    and    badly    ventilated    parlors   in  the 

231 


evening,  neutralize  any  beneficial  effects,  and  the  patient  most 
probably  leaves,  blaming  the  climate  for  the  lack  of  improve- 
ment, when  the  result  is  due  entirely  to  the  fault  of  his  manner 
of  living.  I  have  known  many  a  young  fellow  with  only  a 
slight  trouble  in  his  lungs  to  die  in  the  Adirondacks,  more 
from  the  effects  of  whiskey  than  from  the  disease  itself.  It  is 
difificult  for  many  people  to  adapt  themselves  to  a  methodical 
plan  of  life  long  enough  to  establish  a  permanent  cure  in  con- 
sumption. Personality  has  long  been  a  main  factor  in  deter- 
mining the  prognosis. 

SANATORIUM  TREATMENT  OF  CONSUMPTION 

During  the  last  five  or  ten  years  a  new  method  of  treating 
consumption  has  taken  hold  of  the  medical  profession  of 
this  country  and,  to  a  certain  extent,  of  the  people — namely, 
the  entrance  into  and  continued  residence  in  sanatoriums  espe- 
cially established  and  equipped  in  suitable  localities  for  the 
treatment  of  this  disease.  This  plan  of  treatment  has  been  in 
vogue  in  Europe  and  especially  in  Germany  for  nearly  thirty 
years,  but  it  is  only  in  recent  years  that  the  Americans  have 
adopted  the  method ;  and  even  now  wealthy  Americans  do  not 
take  kindly  to  the  restraints  and  discipline  necessary  in  the  con- 
ducting of  these  institutions.  In  Germany  all  classes,  when  they 
become  consumptive,  the  prince  and  the  pauper,  enter  one  of 
the  innumerable  institutions.  It  is  a  well-known  fact  that  the 
comparison  between  patients  in  the  sanatoriums  situated  in 
favorable  climates  and  patients  in  hotels  and  boarding  houses 
in  the  same  region,  shows  that  the  increase  in  the  number  of 
cures  is  almost  two  to  one  in  favor  of  the  sanatorium,  and  when 
I  explain  to  you  how  these  sanatoriums  are  conducted  you  will 
readily  see  why  this  is  so.  Consumption  is  a  disease  with 
periods  of  quiescence  and  periods  of  exacerbation.  During 
one  of  these  periods  of  exacerbation,  which  are  generally  ac- 
companied by  fever,  increase  of  cough,  and  expectoration  and 
night-sweats,  due,  as  the  patient  generally  thinks,  "to  catching 
cold,"    but   really  to   overexertion,   disturbance  of  digestion, 

232 


and  nervous  excitement,  the  disease  makes  inroads,  and  finally, 
after  one  of  these  acute  attacks,  the  patient  recovers,  but 
hardly  ever  with  the  same  condition  of  the  lungs  as  before,  more 
of  the  lungs  having  been  destroyed.  After  a  longer  or  shorter 
period  of  apparently  good  health,  another  acute  attack  de- 
velops, and  so  on.  Now  the  constant  observation  under  which 
the  patient  is  kept  by  the  trained  medical  men  in  these  sana- 
toriums  enables  them  to  detect  the  least  variance  in  the  patient's 
general  condition,  such  as  slight  fever,  often  so  slight  as  to  be 
imperceptible  to  the  patient,  and  it  is  attended  to  before  any 
headway  is  made.  It  is  the  constant  daily  care  and  close 
observation  of  the  sick  consumptive  and  the  attention  be- 
stowed on  his  manner  of  living  that  turns  the  balance  in  favor 
of  the  sanatorium  patient. 

A  word  as  to  how  sanatoriums  came  to  be  established  for 
the  treatment  of  consumption. 

In  1859,  ^^-  Brehmer  of  Gorbersdorf,  Germany,  having  had 
his  attention  called  to  the  teachings  of  an  obscure  country 
practitioner,  Dr.  George  Bodington,  living  at  Sutton,  Man- 
chester, England,  as  to  the  value  of  pure  air  and  out-of-door 
life  in  the  treatment  of  this  disease,  was  led  to  establish  the 
first  sanatorium,  where  the  suggestions  of  Dr.  Bodington  were 
carried  out.  From  that  day  the  idea  of  sanatoriums  has 
steadily  gained  ground.  They  are  now  in  every  portion  of 
the  world,  and  to-day  in  Germany  alone  there  exist  thirty- 
three  popular  institutions,  many  of  them  established  by  the 
state,  others  by  the  Government  insurance  companies,  and 
still  others  by  philanthropists,  and  some  as  good  invest- 
ments for  capital.  German  insurance  companies  invested  last 
year  over  one  million  dollars  in  sanatoriums  for  consumptives, 
and  expended  nearly  another  million  in  maintaining  these 
institutions. 

England  has  been  for  a  long  time  far  ahead  of  this  country 
in  possessing  several  institutions  for  the  treatment  of  consump- 
tion, as  it  is  well  claimed  that  of  the  reduction  in  the  death-rate 
from  consumption  during  the  last  thirty  years  in  England, 
nearly  one-half  is  directly  traceable  to  the  general  doctrine  of 

233 


the  sanatorium  plan  of  treatment.  What  do  we  mean  by  a 
modern  consumption  sanatorium?  It  is  an  institution  devoted 
to  the  treatment  of  consumption,  situated  in  a  healthy  locality 
free  from  dust  and  dampness,  and  generally  at  some  elevation. 
The  greatest  care  is  exercised  in  the  buildings  and  in  the  sur- 
roundings to  avoid  the  possible  transmission  of  the  disease  to 
employees  or  neighbors  of  the  institution,  and  equal  care  is 
exercised  to  prevent  the  re-infection  of  the  patients  them- 
selves. The  cardinal  rule,  which  is  enforced  in  all  these 
institutions,  is  daily  observed  as  to  the  expectoration  from  the 
patients,  and  the  insistence  that  patients  should  only  spit 
into  certain  prepared  receptacles.  In  the  United  States  at 
the  present  time  there  are  three  kinds  of  consumption 
sanatoriums : 

First.  Those  that  have  been  built  and  supported  entirely  or 
in  part  by  funds  furnished  by  the  various  state  treasuries.  It 
is  only  a  few  years  ago  that  the  first  sanatorium  was  erected 
by  the  state  of  Massachusetts,  at  Rutland.  Recently,  other 
states.  New  York,  New  Jersey,  Iowa,  Maine,  and  Illinois,  have 
taken  steps  in  this  direction,  and  I  believe  that  within  ten 
years  every  state  in  the  Union  will  have  its  own  consumption 
sanatoriums. 

Second.  Sanatoriums  which  have  been  built  and  equipped 
by  philanthropic  people  to  give  climatic  advantages  to  those 
who  are  unable  to  pay  the  excessive  charges  of  boarding- 
houses  and  hotels  in  well-known  health  resorts.  Gener- 
ally the  rate  of  $5  per  week  per  patient  is  charged.  It 
is  impossible  in  most  of  these  institutions  to  care  for  the 
patients  satisfactorily  for  less  than  $8  or  $10  per  patient  per 
week,  and  so  the  "difference  per  patient  between  charge  and 
cost  must  be  made  up  by  contributions  from  philanthropic 
people. 

Third.  Sanatoriums  charging  from  $15  to  $25  per  week. 
At  this  rate  institutions  ought  to  be  self-supporting.  We 
have  at  the  present  day  in  this  country  sanatoriums  for  the 
well-to-do,  sanatoriums  for  those  in  very  moderate  circum- 
stances, but  no  sanatoriums  for  that  large  class  of  consump- 

234 


tives  who  are  unable  to  pay  anything.  Possibly,  when  a  large 
enough  state  sanatorium  has  been  built,  accommodations  can 
be  furnished  for  this  class  of  people,  but  I  question  whether 
enough  can  be  accommodated  to  do  very  much  good.  What 
is  needed  is  just  what  has  already  been  done  in  Germany  with 
wonderful  success :  namely,  each  city  of  any  size  should  estab- 
lish its  own  sanatorium  and  look  after  its  own  consumptive 
poor.  It  has  been  estimated  that  the  amount  of  money  that 
could  be  saved  to  New  York  State,  allowing  a  six-months' 
residence  in  the  sanatorium  and  the  return  of  the  patient  to 
his  occupation  as  wage-earner,  as  would  occur  in  the  majority 
of  cases,  would  be  a  saving  of  over  a  million  dollars  per 
year. 

To  illustrate  how  the  sanatoriums  are  enabled  to  accomplish 
the  rapid  cures  which  are  effected  in  most  of  them,  I  shall 
describe  the  daily  life  of  the  patient  who  has  entered  one  of 
the  large  German  sanatoriums  with  the  disease  f-airly  well 
advanced. 

The  object  of  all  sanatorium  treatment  is  to  have  the  patients 
spend  the  greatest  number  of  hours  in  the  open  air,  and  it  is 
found  that  the  majority  improve  more  rapidly,  especially  during 
the  early  stages  of  their  stay,  by  rest  rather  than  by  exercise. 
Improving  the  general  nutrition  of  the  patients  is  also  another 
object,  and  this  is  accomplished  by  giving  them  as  much  to  eat 
as  they  can  assimilate.  With  these  two  objects  in  view  the 
following  is  the  daily  regime : 

At  eight  o'clock  in  the  morning  a  domestic  enters  the  bed- 
room of  the  patient  and  closes  the  windows,  which  have  re- 
mained open  all  night.  He  lights  a  fire  and  serves  the  first 
breakfast.  After  this  the  patient  arises  and  is  comfortably 
arranged  in  a  long  chair  something  like  a  steamer  chair,  out  of 
doors,  generally  on  a  protected  porch.  His  legs  and  body  are 
warmly  covered  and  often  a  hot-water  bottle,  if  the  weather  is 
cold,  is  placed  at  his  feet. 

About  eleven  o'clock  concentrated  nourishment  is  brought 
to  the  patient :  a  glass  of  milk,  some  egg-nog,  or  bouillon. 
At  twelve  there  is  dinner,  after  which  the  patient   enjoys  a 

235 


promenade,  which  varies  according  to  the  prescription  of  the 
physician.  The  promenade  is  made  on  a  terrace  or  in  a  winter 
garden  connected  with  it.  Afterward  the  patient  resumes  his 
place  in  the  reclining-chair  and  passes  the  whole  afternoon  in  a 
state  of  absolute  repose.  A  quiet  game  of  cards,  dominoes,  con- 
versation, or  reading  is  not  forbidden.  Certain  patients  indulge 
in  profound  sleep,  and  care  should  be  taken  that  this  in  no  way 
interferes  with  the  sleep  of  the  night.  Often  at  four  o'clock 
nourishment  is  brought  to  the  patient.  After  this  dinner  is 
served,  and  after  dinner  another  promenade  shorter  than  that 
in  the  afternoon.  The  person  then  returns  to  the  reclining- 
chair  and  remains  there  until  ten  o'clock  in  the  evening,  and 
then  retires  and  sleeps  in  a  flannel  gown.  The  windows 
should  be  open  all  night.  As  patients  improve  they  are 
allowed  to  take  more  exercise  and  prolong  the  promenade.  In 
sanatoriums  in  this  country  such  a  rigid  regime  is  not  usually 
enforced  unless  the  patient  has  fever.  It  is  a  plan  in  the  best 
sanatoriums  with  which  I  am  acquainted  to  keep  the  patients 
absolutely  in  bed  if  they  are  having  a  high  fever.  In  some  of 
the  sanatoriums  the  beds  are  arranged  on  tracks,  a  plan  which 
enables  them  to  be  wheeled  out  on  the  porch  so  that  the 
patients  can  lie  in  the  open  air. 

CONSTRUCTION  OF  THE  SANATORIUMS 

There  is  a  good  deal  of  difference  in  the  construction  of  the 
sanatoriums  in  Germany,  England,  and  this  country.  The 
European  sanatoriums  almost  always  consist  of  a  central  build- 
ing, which  has  a  dining-room  and  administration  offices,  and 
wings  leading  out  from  either  side  in  which  are  the  bedrooms. 
Along  the  front  of  the  sanatoriums  are  broad  piazzas.  In 
this  country  the  plan  has  been  to  build  a  large  number  of 
small,  detached  cottages,  accommodating  each  from  four  to 
eight  patients,  grouped  about  the  central  building.  On  this 
plan  has  been  built  the  Adirondack  Cottage  Sanitarium  and  the 
sanatorium  at  Liberty,  Sullivan  County.  The  advantages  are 
that  the  patients  are  not  brought  in  such  close  contact  with 

236 


one  another,  the  surroundings  are  much  more  agreeable,  and 
to  a  certain  extent  the  amount  of  fresh  air  obtained  is  greater, 
and  this  advantage  has  caused  the  great  increase  in  the 
building  of  institutions  on  these  plans.  The  extra  heating 
alone  is  a  very  great  item  of  expense,  as  the  amount  of  ac- 
commodation in  sanatoriums  of  the  first  and  second  class  is 
limited ;  and  as  their  object  is  to  do  the  greatest  good  to  the 
greatest  number,  it  is  very  important  that  only  those  cases 
should  be  admitted  who  it  is  believed  can  be  cured  and  sent 
back  to  their  work  in  the  shortest  space  of  time.  From  ex- 
perience of  a  number  of  years  in  examining  a  very  large  num- 
ber of  cases  for  the  Adirondack  sanatorium  and  for  the  one  at 
Liberty,  I  am  fully  convinced  that  six  months  is  the  average 
time  that  is  required  to  bring  about  so  complete  a  cure  that  the 
patient  can  return  to  his  former  life  with  safety.  I  have  seen 
a  number  of  cases  accomplish  this  in  three  months,  but  they 
are  exceptions.  I  believe  all  cases  should  be  admitted  to  state 
and  philanthropic  sanatoriums  on  probation,  and,  if  they  do  not 
show  a  marked  improvement  at  the  end  of  the  month,  should 
make  way  for  others  more  fortunate.  The  object  of  this  care- 
ful selection  can  be  readily  seen  :  as  each  bed  can  accommodate 
only  two,  or  possibly  three,  patients  during  the  year,  it  would 
take  a  large  sanatorium  to  show  permanent  results  in  even  a 
thousand  individuals. 

There  is  a  class  of  sanatoriums  in  Europe,  and  especially  in 
France,  which  have  given  the  most  wonderful  results.  I  refer 
to  what  are  known  as  the  sea-coast  sanatoriums  for  scrofulous 
and  tuberculous  children.  The  statistics  in  Germany  alone 
show  that  fifty  per  cent  of  these  little  ones  leave  these  institu- 
tions perfectly  cured.  We  have  none  in  this  country,  and  we 
say  it  to  our  shame.  Right  here  is  an  opportunity  for  some 
philanthropically  disposed  person.  The  results  from  climatic 
treatment  of  tuberculosis  in  children  far  exceed  those  in  the 
adult. 

To  believe  that  consumption  is  a  curable  disease  one  has 
but  to  consult  the  statistics  furnished  by  the  large  sanatoriums. 
From  any  institutions  which  only  receive  patients  in  the  very 

237 


early  stages  of  the  disease,  seventy  to  seventy-five  per  cent  are 
discharged  cured.  In  most  of  the  sanatoriums  of  Europe, 
where  people  in  all  stages  are  taken,  statistics  show  that 
twenty-five  per  cent  are  absolutely  cured,  and  fifty  per  cent 
leave  much  improved,  and  many  of  them  capable  of  earning 
their  living.  The  question  is  often  raised  if  these  cases  dis- 
charged cured  remain  cured.  Dr.  Trudeau  of  the  Adirondack 
Cottage  Sanitarium,  which  has  been  in  existence  for  about 
fifteen  years,  is  in  constant  communication  with  115  patients 
who  have  been  discharged,  and  while  a  few  have  relapsed 
slightly  the  majority  of  them  are  well  and  living  in  their  own 
homes.  If  people  would  remember  these  statistics  they  would 
not  question  the  curability  of  phthisis,  but  know  that  the  ratio 
of  cure  is  in  proportion  to  the  time  in  the  disease  when  the 
climatic  treatment  is  commenced.  If  the  consumptive  could 
be  impressed  with  the  fact  that  he  might  lose  in  one  week  by 
continuing  his  daily  occupation  what  would  take  him  two 
months  to  regain  under  the  best  climatic  advantages,  there 
would  be  less  procrastination  in  people  who  could  well  afford 
to  make  the  change.  If  I  were  asked  to  what  is  due  the  suc- 
cess of  the  sanatorium  treatment  of  consumption  at  the  present 
day,  I  should  say  it  was  owing  to  the  thorough  and  constant 
supervision  of  the  consumptive,  the  immediate  intervention 
when  new  symptoms  manifest  themselves  or  when  old  ones 
become  aggravated  and  do  not  disappear  readily  enough, 
proper  food  and  drink,  and  the  personal  education  which  the 
patient  receives  from  the  trained  physicians  who  are  devoting 
their  time  to  his  care.  Not  the  most  beautiful  and  healthful 
climate  nor  the  most  delightful  resort  can  cure  the  consumptive 
patient,  if  he  is  not  wisely  guided  in  treatment.  All  that  the 
patient  will  have  learned  from  the  sanatorium  rules  and  regu- 
lations and  the  daily  advice  of  the  physician  is  how  to  protect 
himself  and  others  from  contracting  the  disease ;  how  not  to 
take  cold,  and  how  not  to  lose  what  he  has  gained  during 
precious  hours  of  persistent  effort. 

Certain  signs  of  the  time  point  to  the  fact  that  this  great  city 
of  New  York  will  in  the  near  future  take  care  of  its  consump- 

238 


tive  poor — what  it  should  have  done  long  ago.  It  is  far  behind 
its  sister  cities  in  Europe.  It  will  not  do  this  from  philan- 
thropic motives  but  will  be  forced  to  it  as  a  municipal  ex- 
pedient to  protect  its  citizens  from  the  infection  of  the  thirty 
thousand  consumptives  who  are  walking  its  streets  to-day. 


239 


Appendix  io 
TUBERCULOSIS  AND  ITS  PREVENTION 

By  T.   MITCHELL  PRUDDEN,   M.D. 

Copyright,  1894,  by  Harper  &  Brothers. 

This  article  appeared  in  Harper  s  Magazine,  March,  1894,  and  is  now  reprinted, 
after  revision,  with  the  permission  of  Messrs.  Harper  &  Brothers, 


341 


TUBERCULOSIS   AND    ITS    PREVENTION 

It  is  commonly  neither  wise  nor  necessary  for  people  not 
professionally  concerned  to  think  much  about  disease,  or  weigh 
anxiously  the  chance  or  mode  of  its  acquirement.  But  now 
and  then  conditions  arise  which  demand  general  attention  and 
instruction  regarding  certain  diseases  in  order  that  a  great 
threatened  or  actual  calamity  may  be  averted.  Such  a  con- 
dition faces  the  people  in  all  lands  to-day  in  the  appalling 
prevalence  of  tuberculosis.  A  disease  which  in  mild  or  severe 
form  affects  at  least  one-half  of  the  whole  human  race,  and 
which  causes  the  death  of  full  one-seventh  of  all  who  pass  away, 
killing  about  one-third  of  those  who  perish  between  the  ages 
of  fifteen  and  forty-five, — a  disease  which  is  most  insidious  in 
its  onset,  and  often  relentless  in  its  course,  and  which  may  be 
largely  prevented, — is  one  about  which  we  cannot  be  indiffer- 
ent, and  should  not  longer  be  inactive. 

For  a  long  time  there  has  been  reason  for  believing  that 
tuberculosis  is  a  communicable  disease.  Its  prevalence  in  cer- 
tain families  and  communities,  its  frequent  occurrence  in  those 
who  have  personally  attended  upon  its  victims,  its  onset  in 
those  who  have  occupied  apartments  vacated  by  consumptives 
— such  facts  observed  over  and  over  again  abundantly  justify 
the  belief  in  its  communicability. 

Until  a  few  years  ago  the  cause  of  tuberculosis  was  unknown, 
and  no  definite  data  were  at  hand  which  could  help  us  to  make 
a  feasible  plan  for  limiting  its  ravages.  But  in  these  later  years  a 
great  light  has  been  thrown  upon  this  and  other  kindred  diseases. 

Most  intelligent  people  are  aware  that  within  the  past  two 

343 


decades  a  new  field  in  the  domain  of  life  has  been  opened  and 
widely  explored.  It  has  been  learned  that  in  earth  and  air  and 
water  there  exist  countless  myriads  of  living  things  so  minute 
as  to  lie  far  beyond  the  limits  of  the  unaided  vision,  and  yet 
in  the  aggregate  so  potent  in  the  maintenance  of  the  cycle  of 
life  upon  the  earth  that  without  their  activities  all  life  would 
soon  cease  to  be,  and  the  elements  which  for  a  short  span  fall 
under  the  sway  of  the  life  forces  in  all  higher  animals  and 
plants  would  lapse  finally  and  irrevocably  into  their  primal 
state.  These  tiny  organisms  are  called  germs,  microbes,  or 
micro-organisms.  One  great  and  important  group  of  them 
belongs  among  the  microscopic  plants  called  bacteria. 

These  bacteria  as  a  class  are  so  important  in  the  economy  of 
nature  because  they  live  for  the  most  part  on  dead  organic 
material — that  is,  such  material  as  has  once  formed  a  portion 
of  some  living  thing.  Now  the  world's  store  of  available 
oxygen,  hydrogen,  carbon,  and  nitrogen,  out  of  which  all  liv- 
ing beings  are  largely  formed,  is  limited,  and  if  after  these  have 
served  their  temporary  uses,  as  the  medium  through  which 
that  mysterious  potency  called  life  alone  can  find  expression, 
they  were  not  speedily  released,  new  generations  of  living 
beings  could  neither  assume  nor  maintain  their  place  in  the 
great  cycle  of  life.  And  so  these  tiny  plants,  year  in,  year 
out,  by  day  and  by  night,  unseen  and  mostly  unheeded,  are 
busy  always  in  making  possible  the  return  of  each  year's  visible 
vegetation  and  the  maintenance  of  an  unbroken  succession  of 
generations  in  man  and  beast. 

Different  groups  and  races  among  the  bacteria  have  different 
habitations,  and  vary  widely  in  their  special  powers.  Complex 
and  powerful  as  is  the  aggregate  result  which  they  accomplish 
in  the  world,  the  performances  of  the  individual  are  com- 
paratively simple.  They  are  most  liberally  endowed  with  the 
capacity  for  multiplication,  and  each  germ  acts  as  a  tiny  chemi- 
cal laboratory,  taking  into  itself  the  organic  matter  on  which 
it  feeds,  and  resolving  it  into  new  compounds.  Some  of  the 
latter  are  used  in  building  up  and  maintaining  its  own  body, 
while  others  are  given  off  into  the  surrounding  media. 

244 


We  are  but  just  beginning  to  peer  in  at  the  mysterious  pro- 
cesses which  go  on  under  the  influence  of  the  bacteria  in  this 
underworld  of  life,  and  to  realize  that  all  the  lore  which  un- 
wearied toilers  in  the  past  have  gathered  in  their  studies  of  the 
visible  forms  of  animals  and  plants  makes  but  one  of  the  many- 
chapters  in  nature's  story-book  of  life. 

But  this  new  and  stimulating  point  of  view,  toward  which 
the  studies  of  the  past  decades  have  led  us,  does  not  look  so 
largely  into  the  domain  of  the  practical  that  it  would  greatly 
attract  the  majority  of  business-  and  pleasure-  and  ennui-ridden 
mankind  were  it  not  for  one  very  significant  fact  which  these 
recent  studies  have  revealed.  This  is  that  among  the  myriads 
of  altogether  beneficent  bacteria  which  people  the  earth  and 
air  and  water  there  are  a  few  forms  which  have  chosen  out  of 
all  the  world  as  their  most  congenial  residence  the  bodies  of 
men.  But  even  this  would  be  of  only  passing  interest  to  most 
people  were  it  not  still  further  unfortunately  true  that  in  the 
performance  of  their  simple  life-processes  these  man-loving 
bacteria,  feeding  on  the  tissues  of  their  host,  and  setting  free 
certain  subtle  poisons  in  his  blood,  each  after  its  kind,  can 
induce  those  disturbances  of  the  body's  functions  and  those 
changes  in  its  structure  which  we  call  disease. 

The  diseases  caused  by  the  growth  of  germs  in  the  body  are 
called  infectious.  The  germs  causing  some  of  the  infectious 
diseases  are  given  off  from  the  bodies  of  their  victims  in  such 
form  as  to  be  readily  transmitted  through  the  air  to  others, 
in  whom  they  may  incite  similar  disease.  Such  diseases  are 
spoken  of  as  readily  communicable,  though  it  is  not  actually 
the  disease  itself,  but  only  the  germ  causing  it  which  is  trans- 
mitted. In  other  infectious  diseases  transmission  but  rarely 
occurs.  Many  infectious  diseases  are  very  easily  communi- 
cated from  the  sick  to  the  well  under  unsanitary  and  uncleanly 
conditions,  which  with  proper  care  are  very  little  liable  to 
spread. 

I  need  not  here  put  on  parade  the  whole  uncanny  list  of 
germ  diseases,  in  which  tuberculosis  stands  foremost,  followed 
by  pneumonia,  diphtheria,  typhoid  fever,  and  the  rest.     Nor 

245 


need  I  call  to  mind  the  means  by  which  our  growing  knowledge 
in  this  domain  has  day  by  day  been  laid  under  tribute  for  sug- 
gestions of  hope  and  safety  for  the  stricken.  It  is  a  record  of 
brilliant  conquest  in  nature,  and  already  of  far-reaching  benefi- 
cence to  man. 

But  the  great  fundamental  advance  which  signalizes  the  past 
decade  is  the  lifting  of  this  whole  class  of  fateful  germ  diseases 
out  of  the  region  of  the  intangible  and  mysterious,  and  their 
establishment,  on  the  basis  of  positive  experimental  research, 
in  the  domain  of  the  comprehensible  and  definite.  The  things 
which  cause  them  are  no  longer  for  us  mysterious  emanations 
from  the  sick,  or  incorporate  expressions  of  malign  forces 
against  which  conjurations  or  prayers  could  alone  promise  pro- 
tection. But  they  are  particulate  beings,  never  self-engendered, 
never  evolved  in  the  body,  always  entering  from  without — 
things  which  we  can  see  and  handle  and  kill. 

Let  us  now  glance  at  the  germ  called  the  tubercle  bacillus, 
the  germ  which  causes  and  which  alone  can  cause  tuberculosis. 
It  does  not  exist  in  the  body  of  men  or  animals  in  health. 
Without  the  entrance  of  this  particular  germ  into  the  human 
body  from  without,  tuberculosis  cannot  develop  in  it.  With- 
out the  transmission  of  this  germ  in  some  way  or  other  in  a 
living  condition  from  the  sick  to  the  well,  tuberculosis  cannot 
spread.  In  the  life  story  of  this  tiny  germ  lie  both  the  potency 
for  mischief  which  we  deplore  and  the  secret  of  our  release 
from  its  bondage. 

The  tubercle  bacillus  is  a  little  colorless  rod-like  plant,  so 
small  that  even  many  thousands  of  them  piled  together  would 
make  a  heap  still  far  too  small  to  be  visible  to  the  naked  eye. 
It  cannot  move  about,  nor  can  it  grow  without  moisture,  nor 
at  a  temperature  much  above  or  much  below  that  of  the  human 
body.  The  material  on  which  it  feeds  must  be  very  nicely 
adapted  to  its  requirements,  and  it  has  no  lurking  or  growing 
places  in  nature  outside  of  the  bodies  of  men  and  a  few  warm- 
blooded animals.  It  can  be  cultivated  artificially  in  the  labora- 
tory, and  we  know  more  about  its  life  and  peculiarities  than 
about  almost  any  other  germ.     While  it  can  remain  alive  in  a 

246 


dried  state  for  many  weeks,  it  is  readily  killed  by  heat,  by  sun- 
light, and  by  many  of  those  chemical  substances  which  we  call 
disinfectants.  It  does  not  flourish  equally  well  in  the  bodies 
of  all  human  beings. 

When  once  it  gains  lodgment  in  a  body  suited  to  its  growth 
it  multiplies  slowly,  each  germ  dividing  and  subdividing,  tak- 
ing from  the  tissues  material  for  its  growth,  and  returning  to 
them  certain  subtle  poisons  which  it  sets  free.  The  action  of 
the  tubercle  bacillus  is  peculiar  in  that  it  stimulates  the  cells 
of  the  body,  wherever  it  may  lodge  and  grow,  to  the  formation 
of  little  masses  of  new  tissue,  which  we  call  tubercles.  These 
tubercles  are,  as  a  rule,  short-lived,  and,  if  the  disease  progresses, 
tend  to  disintegrate.  If  the  tubercles  have  grown  in  such  situ- 
ations as  make  this  possible,  as  in  the  intestinal  canal  or  the 
lungs,  the  disintegrated  and  broken-down  material,  often  con- 
taining myriads  of  the  living  germs,  may  be  cast  off  from  the 
body.  In  tuberculosis  of  the  lungs,  or  consumption,  this  waste 
material  is  thrown  off  with  the  sputum.  While  almost  any 
part  of  the  body  may  be  affected,  tuberculosis  of  the  lungs  is 
by  far  the  most  common  form  of  the  disease. 

It  follows  from  what  has  been  said  that  the  only  way  in 
which  we  can  acquire  tuberculosis  is  by  getting  into  our  bodies 
tubercle  bacilli  from  tuberculous  men  or  animals.  The  only 
animals  liable  to  conve}^  the  disease  to  man  are  tuberculous 
cattle,  and  these  through  the  use  of  either  meat  or  milk.  The 
danger  from  the  use  of  uncooked  meat  or  the  unboiled  milk 
from  tuberculous  cattle  is  real  and  serious,  but  it  will  not  be 
considered  here  at  length,  because  the  great  and  prevailing 
danger  of  infection  comes  from  another  source. 

Almost  as  soon  as  the  significance  of  the  tubercle  bacillus 
was  established,  a  series  of  studies  was  undertaken  on  the  pos- 
sibility of  the  spread  of  the  disease  by  the  breath  or  exhala- 
tions of  the  persons  of  consumptives.  These  studies  at  once 
showed  that  the  tubercle  bacillus  cannot  be  given  off  into  the 
air  of  the  breath  from  the  moist  surfaces  of  the  mouth  and  air 
passages,  nor  from  any  material  which  may  come  from  them 
while  it  remains  moist,  nor  from  healthy  unsoiled  surfaces  of 

247 


the  body.  The  establishment  of  this  fact  is  of  far-reaching 
consequence,  because  it  shows  that  neither  the  person  nor  the 
breath  of  the  consumptive  is  a  direct  source  of  danger  even  to 
his  most  constant  and  intimate  attendants. 

While  the  discharges  from  the  bowels  in  persons  suffering 
from  tuberculosis  of  the  intestinal  tract  may  contain  many 
living  bacilli,  the  usual  mode  of  disposal  of  these  discharges 
protects  us  from  any  considerable  danger  from  this  source. 

It  is  the  sputum  after  its  discharge  from  the  body  on  which 
our  attention  must  be  fixed.  While  the  sputum  is  moist  it 
can,  as  a  rule,  do  no  harm,  unless  it  should  be  directly  trans- 
mitted to  those  who  are  well  by  violent  coughing,  or  sneezing, 
by  the  use  of  uncleansed  cooking  or  eating  utensils,  by  soiled 
hands,  or  by  such  intimate  personal  contact  as  kissing  or 
fondling.  But  if  in  any  way  the  sputum  becomes  dried,  on 
floors  or  walls  or  bedding,  on  handkerchiefs  or  towels,  or  on 
the  person  of  the  patient,  it  may  soon  become  disseminated  in 
the  air  as  dust,  and  can  then  be  breathed  into  the  lungs  of  ex- 
posed persons.  This  germ-laden  material  floating  in  the  air 
may  be  swallowed,  and  thus  enter  the  recesses  of  the  body 
through  other  portals  than  the  lungs,  but  these  are  the  most 
vulnerable  and  accessible  organs. 

The  wide  distribution  of  tubercle  bacilli  in  the  air  of  living- 
rooms,  and  in  other  dusty  places  where  people  go,  is  due  partly 
to  the  frequency  of  the  disease,  and  the  large  numbers  of  living 
bacilli  which  are  cast  off  in  the  sputum  (sometimes  millions  in 
a  day),  and  partly  to  the  fact  that  many  of  the  victims  of  con- 
sumption go  about  among  their  fellows  for  purposes  of  business 
or  pleasure  for  months  or  years.  So  each  consumptive,  if  not 
intelligently  careful,  may  year  after  year  be  to  his  fellow-men 
a  source  of  active  and  serious  and  continual  infection. 

This,  then, — the  dried  uncared-for  sputum  of  those  suffering 
from  pulmonary  tuberculosis, — is  the  great  source  of  danger; 
this  the  means  so  long  concealed  by  which  a  large  part  of 
the  human  race  prematurely  perishes.  Let  but  this  discharged 
material  be  rendered  harmless  or  destroyed  in  all  cases  before 
it  dries,  and  the  ravages  of  this  scourge  would  largely  cease. 

248 


This  is  not  a  theoretic  matter  only,  for  again  and  again  have  the 
living  and  virulent  germs  been  found  clinging  to  the  walls  and 
furniture  and  bedding  and  handkerchiefs  of  consumptive  per- 
sons, and  in  the  dust  of  the  rooms  in  which  they  dwell. 

A  malady  whose  victims  far  outnumber  those  of  all  other 
infectious  diseases  put  together,  sparing  neither  rich  nor  poor, 
seizing  upon  life  while  it  is  as  yet  only  a  promise,  but  most 
inexorable  in  the  fulness  of  its  tide — this  malady  can  be  largely 
prevented  by  the  universal  and  persistent  practice  of  intelligent 
cleanliness. 

We  have  learned  in  the  past  few  years  one  fact  about  tuber- 
culosis which  is  of  incalculable  comfort  to  many,  and  that  is 
that  the  disease  is  not  hereditary.  It  is  very  important  that 
we  should  understand  this,  because  it  seems  to  contradict  a 
long-prevalent  tradition,  and  a  belief  still  widely  and  sorrow- 
fully entertained.  Bacteria,  and  especially  most  disease-pro- 
ducing bacteria,  are  very  sensitive  in  the  matter  of  growth  and 
proliferation  to  the  conditions  vmder  which  they  are  placed, 
and  especially  to  the  material  on  which  they  feed.  So  that  a 
germ  which  can  induce  serious  disease  in  one  species  of  animal 
is  harmless  in  the  body  of  a  different  though  closely  allied 
form.  More  than  this,  different  individuals  of  the  same  spe- 
cies, or  the  same  individual  at  different  times,  may  have  the 
most  marked  differences  in  susceptibility  in  the  presence  of 
disease-producing  germs.  What  this  subtle  difference  is  we 
do  not  know.  Whether  the  body  at  one  time  affords  a  con- 
genial soil  to  the  invading  germs  and  at  another  does  not ; 
whether  its  marvellous  and  complex  powers  of  resisting  the 
virulent  tendencies  of  disease-producing  bacteria  at  one  period 
or  in  one  individual  are  more  vigorous  than  in  another  and 
vary  at  different  times,  we  do  not  certainly  know.  This,  how- 
ever, we  do  know,  that  certain  individuals  are  more  likely 
than  others  to  yield  to  the  incursions  of  the  tubercle  bacillus. 
This  vulnerability  in  the  presence  of  invading  germs  we  call 
susceptibility,  and  susceptibility  to  the  action  of  the  tubercle 
bacillus  is  hereditary. 

It  is  not  the  disease,   tuberculosis,  which  comes  into  the 

249 


world  with  certain  individuals  or  with  successive  children  of 
the  same  family,  but  the  aptitude  to  contract  it  should  external 
conditions  favor. 

However  much  the  child  of  tuberculous  parents  or  a  member 
of  a  tuberculous  family  may  be  predisposed  to  the  disease,  he 
cannot  acquire  tuberculosis  unless  by  some  mischance  the  fate- 
ful germ  enters  his  body  from  without.  What  has  been  re- 
garded through  all  these  years  as  the  strongest  proof  of  the 
hereditary  transmission  of  tuberculosis — namely,  the  occur- 
rence of  the  disease  in  several  members  of  the  same  household 
— is,  in  the  new  light,  simply  the  result  of  household  infection 
— the  breathing  of  air  peculiarly  liable  to  contain  the  noxious 
germs,  or  their  entrance  in  some  other  way  into  the  bodies  of 
persons  especially  sensitive  to  their  presence. 

I  do  not  mean  to  imply  that  under  no  conditions  can  the 
tubercle  bacillus  be  transmitted  from  the  mother  to  the  child 
before  its  birth.  In  a  few  instances  this  is  believed  to  have 
happened.  But  its  occurrence  is  so  extremely  infrequent  that 
it  may  be  regarded  as  accidental,  and  of  no  serious  importance 
from  our  present  point  of  view. 

But  it  will  perhaps  be  said:  "If  the  tubercle  bacilli  are  so 
widely  diffused,  why  do  we  not  all  acquire  tuberculosis,  and 
why  was  the  world  not  long  since  depopulated?  "  In  order  to 
explain  this  matter  I  must  ask  the  reader  to  look  with  me  for 
a  moment  at  some  of  the  body's  natural  safeguards  against 
bacterial  and  other  invaders  from  the  air. 

It  has  been  found  that  a  person  breathing  in  germ-  and 
dust-laden  air  through  the  nose  breathes  out  again  air  which 
is  both  dust-  and  germ-free.  The  air  passages  of  the  nose  are 
tortuous,  and  lined  with  a  moist  membrane,  against  which  the 
air  impinges  in  its  passage.  On  these  moist  surfaces  most 
of  the  solid  suspended  particles,  the  germs  among  them,  are 
caught  and  held  fast,  and  may  be  thrown  off  again  in  the  se- 
cretion. In  breathing  through  the  mouth  this  safeguard  is  not 
utilized.  Again,  the  upper  air  passages  leading  to  the  lungs 
are  lined  with  a  delicate  membrane  of  cells,  whose  free  surfaces 
are  thickly  beset  with  tiny  hairlike  projections.     These  pro- 

250 


jections  are  constantly  moving  back  and  forth  with  a  quick 
sweep,  in  such  a  way  that  they  carry  small  particles  which 
may  have  escaped  the  barriers  above,  up  into  the  mouth,  from 
which  they  may  be  readily  discharged.  In  this  way  much  of 
the  evil  of  breathing  dust-  and  germ-laden  air  is  averted.  But 
in  spite  of  these  natural  safeguards  a  great  deal  of  foreign 
material,  under  the  ordinary  conditions  of  life  in-doors  or  in 
dusty  places,  does  find  lodgment  in  the  delicate  recesses  of 
the  lungs.  The  body  tolerates  a  good  deal  of  the  deleterious 
material,  but  its  overtasked  toleration  fails  at  last,  when  serious 
disease  may  ensue. 

When  ordinary  forms  of  living  bacteria  get  into  the  tissues 
of  the  body,  a  very  complex  cellular  mechanism,  not  fully 
understood,  usually  leads  to  their  destruction  and  ultimate 
removal.  In  the  presence  of  the  tubercle  bacillus  the  body 
cells  are  often  able  to  build  a  dense  enclosing  wall  around  the 
affected  region,  shutting  it  off  from  the  rest  of  the  body.  This 
is  one  of  the  modes  of  natural  cure. 

The  body  cells  are  sometimes  able,  if  sustained  by  nourish- 
ing food  and  an  abundance  of  fresh  air,  to  carry  on,  year  after 
year,  a  successful  struggle  with  the  invading  germs,  so  that  the 
usefulness  and  enjoyment  of  life  are  but  little  interfered  with. 
Finally,  a  certain  proportion  of  human  beings  seem  to  be  en- 
dowed at  birth  with  some  as  yet  unknown  quality  in  the  cells 
or  fluids  of  the  body  which  naturally  unfits  them  for  the  life 
uses  of  the  tubercle  bacillus,  and  so  renders  the  individual  for 
longer  or  shorter  periods  practically  immune.  Others,  on 
the  contrary,  are,  as  we  have  seen,  from  birth  unusually  sus- 
ceptible. 

This  inherited  susceptibility  to  the  incursions  of  the  tubercle 
bacillus,  should  this  find  lodgment  in  the  body  from  without, 
by  no  means  always  reveals  itself  in  any  apparent  lack  of 
vigor  or  robustness  of  the  body.  Still,  any  habit  or  mode  of 
life  which  diminishes  the  bodily  vigor,  whether  in  those  predis- 
posed to  this  malady  or  in  the  apparently  immune,  and  gives 
it  a  leaning  toward  disease,  diminishes,  as  a  rule,  the  chances 
of  a  successful  contest  with  the  bacillus. 

351 


Thus  it  is  that  in  spite  of  the  wide  distribution  of  these  fate- 
ful germs  in  frequented  places,  and  the  tendency  of  certain 
vulnerable  persons  to  succumb  to  their  ravages,  so  many- 
people  are  not  affected  by  them,  and  so  many,  although  not 
altogether  escaping  their  malign  influence,  are  yet  able  to  wrest 
at  least  a  moiety  of  life  from  the  hands  of  the  great  destroyer. 

The  degree  of  success  which  may  attend  our  crusade  against 
tuberculosis  will  largely  depend  upon  the  wide  diffusion  of  the 
knowledge  of  its  communicability  by  means  of  the  sputum, 
dried  and  powdered  and  floating  in  the  air  as  dust,  and  the  in- 
telligent persistence  with  which  the  peccant  material  may  be 
safely  cared  for  at  its  sources. 

The  resolute  avoidance  by  consumptives  of  the  not  only 
filthy  but  dangerous  practice  of  spitting  upon  floors  or  streets, 
or  anywhere  else  except  into  proper  receptacles  ;  the  use  of  re- 
ceptacles which  may  be  and  are  frequently  and  thoroughly 
cleaned,  and,  best  of  all,  of  water-proof  paper  cups,  which  with 
their  contents  may  be  burned ;  or,  when  circumstances  require, 
the  receiving  of  the  dangerous  material  on  cloths  or  Japanese 
paper  napkins,  which  may  be  destroyed  by  fire,  and  not  on 
more  valuable  handkerchiefs  on  which  the  sputum  is  allowed 
to  dry  while  in  use  or  before  disinfection  and  washing;  scrupu- 
lous care  by  others  of  the  sputum  of  those  too  ill  to  care  for  it 
themselves — these  are  the  comparatively  simple  means  from 
which  we  may  most  confidently  expect  relief.  The  details  of 
these  precautions  and  their  adaptation  to  the  special  circum- 
stances of  those  suffering  from  tuberculosis  can  most  wisely  be 
left  to  the  physician,  and,  though  of  paramount  importance, 
need  not  further  engage  our  attention  here. 

To  the  consumptive  himself  these  measures  are  not  without 
a  vital  significance.  For  his  chances  of  recovery  may  be 
diminished  in  no  small  degree  if  he  be  more  or  less  constantly 
liable  to  a  fresh  infection  from  material  which  he  has  once  got 
rid  of,  and  which  should  have  been  destroyed. 

The  great  volumes  of  fresh  moving  air  which  we  encounter 
out-of-doors  in  properly  cleansed  streets  usually  so  greatly 
dilute  the  dust,  of  whatever  kind,  that  little  apprehension  need 

252 


be  felt  from  its  presence.  When,  however,  in  crowded  cities, 
the  streets  are  filthy,  and  but  fitfully  cared  for;  when  choking 
dust  clouds  must  be  encountered  by  the  citizen  in  the  hap- 
hazard and  slatternly  essays  at  cleaning  which  untrained,  irre- 
sponsible, or  decrepit  attaches  of  vicious  administrations  may 
deign  to  make — we  cannot  ignore  a  danger  from  street  dust 
which  may  well  incite  the  gravest  apprehension.  The  citizen 
can,  if  he  must,  avoid  a  block  on  which  the  hand-sweepers,  in 
utter  disregard  of  rules,  ply  their  nefarious  brooms  over  unwet 
surfaces,  because  too  indolent  or  indifTerent  to  sprinkle  them 
— this  he  can  do  if  he  be  not  willing  or  ready  t6  apply  the 
citizen's  remedy  for  municipal  misrule. 

But  it  is  in  rooms  either  of  dwelling  or  assembling  places 
that  the  ill  effects  of  infectious  dust  are  most  potent,  because 
the  air  is  here  not  so  constantly  renewed  as  it  is  out-of-doors, 
and  is  liable  to  be  breathed  over  and  over  again.  Dust  which 
gets  into  houses  does  not  readily  leave  them,  unless  special 
and  intelligent  means  be  directed  to  its  removal.  We  do  not 
usually  realize  that  though  the  air  itself  in  inhabited  rooms 
is  constantly  changing  more  or  less  rapidly  by  diffusion,  by 
draughts,  or  by  purposed  ventilation,  fine  dust  particles  are 
not  removed  under  the  same  influences  in  proportionate  de- 
gree. They  cling  more  or  less  tenaciously  to  all  surfaces  on 
which  they  have  settled,  and  especially  to  fabrics,  so  that  cur- 
rents of  abundant  force  and  sufficient  distribution  to  change 
the  air  may  and  usually  do  leave  the  lodged  dust  particles 
almost  entirely  undisturbed. 

One  of  the  most  threatening  tendencies  of  modern  times  in 
matters  of  health  is  to  overcrowding  in  cities.  The  great  ele- 
ment of  danger  from  this  overcrowding  is  not  only  the  insuf- 
ficiency of  air  in  living-rooms,  and  the  lack  of  ready  means  for 
its  renewal,  but  the  accumulation  in  this  air  of  infectious  germs 
floating  with  the  dust.  Abundant  water-supply  and  good 
sewerage  have  rendered  possible  and  measurably  safe,  so  far  as 
the  ordinary  waste  of  life  is  concerned,  the  building  of  vast 
tenements  which  swarm  with  people.  But  the  means'  of  get- 
ting pure  air,  and  especially  of  disposing  of  infectious  material 

253 


often  floating  in  it  when  it  is  confined,  have  not  at  all  kept 
pace  with  the  demands  of  health  and  cleanliness. 

But  when  we  turn  to  the  larger  and  more  liberally  furnished 
dwellings  of  the  well-to-do  classes,  we  do  not  find  everything 
reassuring  from  the  standpoint  of  hygiene,  for  in  some  respects 
the  rich  are  sadly  handicapped  by  the  "tyranny  of  things." 
Of  course  long-  and  thick-piled  carpets  afford  persistent  lurking- 
places  for  infectious  as  well  as  other  dust.  Certainly  heavy 
hangings  in  a  measure  hinder  the  purifying  action  of  the  sun- 
light, shut  the  used  air  in  and  the  fresh  air  out,  and  shelter 
floating  matter  which  might  otherwise  escape.  Without  doubt 
complex  upholstery  with  roughened  fabrics  increases  the  diffi- 
culties in  the  maintenance  of  cleanliness.  But  the  usage  of 
the  householder  in  these  matters  will,  after  all,  depend  upon 
whether  his  practical  devotion  be  most  at  Fashion's  or  Hygeia's 
shrine.  We  well  may  long  for  the  coming  of  a  time  when 
clean,  airy,  simply  furnished  living-rooms  shall  replace  the 
stuffy  fabric-strewn  apartments  in  which  the  fashionable  citizen 
so  much  delights  to-day. 

In  one  particular,  however,  the  devotee  to  cleanliness  may 
be  unreservedly  insistent,  and  that  is  that  in  the  cleaning  of 
living-rooms,  whether  occupied  by  the  sick  or  the  well,  the 
distinct  and  recognized  purpose  of  the  operation  shall  be  to 
remove,  and  not  simply  to  stir  up,  the  over-gathering  dust. 

The  past  few  years,  so  beneficently  signalized  by  the  reve- 
lations of  the  new  germ  lore,  have  seen  marked  departures 
from  the  traditional  sweepings  and  dustings  of  a  past  era ;  and 
the  emancipation  of  the  housekeeper,  and  incidentally  of  the 
household,  from  the  thrall  of  the  pestiferous  feather  duster 
seems  fairly  under  way.  Still,  some  of  the  old  barbarous 
travesties  upon  cleaning  widely  persist.  The  dry  broom  still 
seeks  out  in  the  deep  recesses  of  the  carpets  not  the  coarser 
particles  of  dirt  alone,  but  the  hordes  of  living  germs  which 
were  for  the  time  safely  ensconced ;  and  among  these  what 
malignant  forms  the  chances  of  the  day  may  have  mingled. 
These  are  all  set  awhirl  in  the  air ;  some  gather  on  salient 
points  of  the  fittings   and  furnishings ;    many   stay   with   the 

254 


operator,  to  vex  for  hours  the  delicate  breathing  passages  or 
the  deeper  recesses  of  the  lungs.  Then  in  the  lull  which  fol- 
lows gravity  reasserts  its  sway,  and  the  myriad  particles,  both 
the  living  and  the  dead,  slowly  settle  to  the  horizontal  surface, 
especially  to  the  carpets.  Then  the  feather  duster  comes 
upon  the  scene,  and  another  cyclone  befalls.  The  result  of 
it  all  is  that  the  dust  has  finally  been  forced  to  abandon  more 
or  less  completely  the  smooth  and  shining  surfaces  where  it 
would  be  visible,  and  is  largely  caught  in  the  surface  rough- 
nesses of  the  carpets  or  upholstery  or  hangings,  ready  at  the 
lightest  footfall  or  the  chariest  touch  to  dance  into  the  air 
again,  and  be  taken  into  the  lungs  of  the  victims  of  the  pre- 
vailing delusion — the  delusion  that  the  way  to  care  for  always 
noxious  and  offensive  and  often  dangerous  dust  is  not  to  get 
it  out  of  the  house,  but  to  keep  it  stirring  in  the  air  until  at 
last  it  has  settled  where  it  does  not  vex  the  eye. 

By  the  use  of  moist  tea-leaves  in  the  sweeping  of  carpets,  by 
the  use  of  soft-textured  fabrics,  frequently  shaken  out-of-doors, 
or  by  moist  cloths  or  chamois  in  dusting,  much  useless  dust- 
scattering  may  be  avoided.  But  no  matter  what  the  means 
employed,  the  final  purpose  of  every  household  cleaning  should 
be  to  get  the  dust,  not  afloat,  but  away. 

Probably  the  most  serious  source  of  infection  which  one  is 
liable  to  encounter  in  the  usual  ways  of  life  is  the  occupancy 
at  hotels  of  bedrooms  vacated  by  consumptives  without  subse- 
quent efficient  disinfection  and  cleansing,  and  travel  in  sleep- 
ing-cars. I  need  not  enter  here  into  the  harrowing  details  of 
desperate  uncleanness  which  the  ordinary  railway  travel  brings 
to  light.  It  is  to  be  hoped  that  popular  demand  for  reform  in 
the  routine  of  hotel-keepers  and  railroad  managers  in  the  mat- 
ter of  ordinary  sweeping  and  dusting,  and  in  the  precautions 
against  the  spread  of  tuberculosis,  may  soon  usher  in  among 
them  a  day  of  reasonable  sanitary  intelligence. 

A  belief  in  the  communicability  of  tuberculosis  is  becoming 
widely  diffused,  and  it  would  seem  to  be  desirable,  on  the 
ground  of  policy  alone,  for  the  managers  of  summer,  and 
especially  of  winter,  resorts  frequented  by  consumptives,  to  let 

255 


it  be  known  in  no  uncertain  way  that  their  precautions  against 
the  spread  of  infectious  diseases  are  effectually  in  line  with  the 
demands  of  modern  sanitary  science. 

The  members  of  families  bearing  a  hereditary  susceptibility 
to  the  acquirement  of  tuberculosis  should  strive  to  foster  those 
conditions  which  favor  a  healthy,  vigorous  life,  in  occupation, 
food,  exercise,  and  amusement,  and  remember  that  for  them 
more  than  for  others  it  is  important  to  avoid  such  occupations 
and  places  as  favor  the  distribution,  in  the  air  or  otherwise,  of 
the  tubercle  bacillus. 

But  when  the  individual  has  done  what  he  can  in  making  his 
surroundings  clean,  and  in  thus  limiting  the  spread  of  the  tu- 
bercle bacillus,  there  still  remains  work  for  municipal  and  State 
and  national  authorities  in  diffusing  the  necessary  knowledge 
of  the  disease  and  its  modes  of  prevention ;  in  directly  caring 
for  those  unable  to  care  for  themselves ;  in  securing  for  all, 
such  freedom  from  contact  with  sources  of  the  disease  as  the 
dictates  of  science  and  humanity  may  require  and  the  law 
permit. 

To  health  boards,  either  national  or  local,  must  largely  be 
intrusted  the  primary  protection  of  the  people  against  the 
danger  from  tuberculous  cattle. 

A  national  bureau  of  health  might  be  of  incalculable  service 
in  stimulating  and  harmonizing  efforts  made  for  the  suppres- 
sion of  tuberculosis  in  various  parts  of  the  land,  and  in  foster- 
ing research  in  lines  which  promise  large  practical  return  in 
the  saving  of  life. 

The  United  States  has  been  keenly  alive  to  the  economic 
importance  of  certain  diseases  of  cattle,  and  has  done  much  to 
suppress  among  them  various  infectious  maladies.  But  the 
most  positive  official  relationship  which  the  United  States  has 
thus  far  borne  to  this  communicable  and  preventable  disease 
of  man  which  robs  it  each  year  of  hundreds  of  thousands  of  its 
citizens,  has  been  to  place  and  maintain  a  heavy  tax  upon 
instruments  and  apparatus  necessary  for  the  recognition  and 
study  of  tuberculosis  and  many  other  bacterial  diseases,  and, 
except  recently  and  for  a  favored  few,  upon  books  in  which, 

256 


and  in  which  alone,  can  be  found  records  of  research  upon 
which  the  means  for  the  prevention  of  tuberculosis  must  be 
based. 

Tuberculosis  in  this  country  has  been  officially  almost  en- 
tirely ignored  in  those  practical  measures  which  health  boards 
universally  recognize  as  efficient  in  the  suppression  of  this  class 
of  maladies.  Physicians  are  now  required  to  report  it  to  the 
local  health  boards  in  but  few  cities.  Systematic  measures 
of  disinfection  are  rarely  practised.  But  the  official  measures 
just  mentioned  have  been  found  extremely  useful  in  the  limi- 
tation of  other  communicable  diseases.  While  consumption  is 
a  communicable  germ  disease,  it  is,  in  fact,  in  the  light  of  our 
present  knowledge,  when  intelligently  cared  for,  so  little  liable 
to  spread  that  it  is  properly  exempt  from  those  summary 
measures  which  health  authorities  are  justified  in  adopting 
with  the  more  readily  and  less  avoidably  communicable  mala- 
dies which  we  call  contagious.  Consumption  is  apt  to  involve 
such  prolonged  illness,  and  so  often  permits  affected  persons 
for  months  and  years  to  go  about  their  usual  avocations,  that 
general  isolation  would  be  both  impracticable  and  inhumane. 
Moreover,  for  reasons  which  it  is  hoped  are  evident  to  the 
reader,  isolation  among  those  capable  of  caring  for  themselves 
is  at  present  entirely  unnecessary. 

But  while  extreme  measures  are  not  called  for,  local  health 
boards  must  soon  act  in  the  prevention  of  tuberculosis.  For 
the  present  the  wisest  course  would  seem  to  be  to  attempt  to 
secure  the  desired  ends  rather  by  instruction,  counsel,  and 
help  than  by  direct  and  summary  procedures. 

Thanks  largely  to  the  persistent  efforts  of  Dr.  H.  M.  Biggs 
through  many  discouraging  years,  the  city  of  New  York  stands 
foremost  to-day  among  municipalities,  great  or  small,  the 
world  over,  in  its  intelligent  and  systematic  official  efforts  to 
suppress  the  ravages  of  tuberculosis.  But  the  task  is  difficult, 
advance  is  slow,  and  the  facilities  at  hand  are  utterly  in- 
adequate. 

There  is  no  more  pitiable  spectacle  in  this  land  to-day  than 
that  of  the  hundreds  of  victims  of  advanced  tuberculosis  in 

257 


every  large  town  who  cannot  be  comfortably  or  safely  cared 
for  in  the  dwellings  of  the  poor,  and  yet  who  are  always  un- 
welcome applicants  at  most  of  our  hospitals,  and  at  many  are 
denied  admission  altogether.  They  are  victims  of  ignorance 
and  of  vicious  social  and  hygienic  conditions  for  which  they 
are  not  largely  responsible,  and  States  and  municipalities, 
which  are  more  to  blame,  owe  them  at  least  a  shelter  and  a 
place  to  die.  Unquestionably  one  of  the  urgent  duties  im- 
mediately before  us  in  all  parts  of  the  land  where  tuberculosis 
prevails  is  the  establishment  of  special  hospitals  in  which  this 
disease  can  be  treated  and  its  victims  safely  cared  for. 

And  now  at  last  remains  to  be  spoken  what  word  of  cheer 
and  hope  our  new  outlooks  may  have  given  us  for  those  who 
are  already  under  the  shadow  of  this  sorrowful  affliction.  The 
dreams  and  aspirations  and  strenuous  labors  of  the  students  of 
this  disease  have  looked  steadily  toward  the  discovery  of  some 
definite  and  positive  means  of  cure,  but  as  yet  full  success 
lingers  beyond  their  grasp.  The  methods  for  the  early  detec- 
tion of  tuberculosis  which  science  has  pointed  out  make  it 
possible  for  affected  persons  to  plan  such  modes  of  life  and 
early  seek  such  salubrious  climates  as  promise  a  hope  of  re- 
covery. We  have  studied  closely  the  ways  in  which  the  cells 
of  the  body  often  successfully  resist  the  incursions  of  the 
already  seated  germs,  and  learned  how  in  many  ways  the 
natural  forces  of  cure  may  be  sustained  and  strengthened. 
We  have  learned  much  about  certain  complicating  occurrences 
which  often  form  the  most  serious  features  in  the  progress  of 
tuberculosis  of  the  lungs,  and  how  they  may  be  best  avoided. 
And  so  to-day  the  outlook  for  those  in  the  earlier  stages  of 
this  disease  is  in  a  considerable  proportion  of  cases  extremely 
encouraging.  It  is  no  longer  for  us  the  hopeless  malady  which 
it  was  earlier  believed  to  be.  It  is  not  necessarily  a  bitter 
losing  fight  upon  which  one  enters  who  becomes  aware  that 
the  finger  of  this  disease  is  upon  him.  A  long  and  happy  and 
useful  life  may  still  be  his  if  the  conditions  which  favor  his  cure 
be  early  and  intelligently  fixed  upon,  and  patiently  and  faith- 
fully persisted  in.     The  wise  physician  is  here  the  best  adviser 

258 


in  climate  and  regimen,  as  well  as  in  the  proper  selection  of 
remedial  measures,  and  the  earlier  his  counsel  is  sought  and 
acted  on,  the  brighter  will  usually  be  the  outlook  for  recovery. 
The  great  and  beneficent  work  which  has  been  accomplished 
by  Trudeau  in  the  Adirondack  woods,  in  at  once  widening  the 
bounds  of  knowledge  of  tuberculosis  and  in  carrying  to  a  suc- 
cessful issue  in  so  many  the  varied  and  delicate  processes  of 
cure,  is  a  cheering  example  of  what  may  be  accomplished  by 
the  light  of  our  new  knowledge,  in  mastering  a  malady  so  long 
considered  hopeless. 


259 


Appendix  ii 

WARFARE  AGAINST  CONSUMPTION 

WILL  YOU   HELP  FIGHT  IT? 
WHY?     HOW? 


261 


WARFARE   AGAINST   CONSUMPTION 

WHY   FIGHT   IT? 

Because  more  people  die  of  consumption  than  from  any 
other  disease. 

Each  year  1,095,000  of  the  people  of  the  world  die  of  it.  In 
the  United  States  over  100,000  die  every  year  of  consumption. 
Every  day  3000,  and  each  minute  of  the  day  two  persons  fall 
before  this  enemy.     How  many  of  your  friends  have  died  of  it? 

Because  it  is  a  disease  which  spreads  from  one  person  to  an- 
other, and  any  one  may  catch  it. 

Because  it  is  chiefly  caused  by  the  filthy  habit  of  spitting. 

Because  it  is  a  disease  which  can  be  stopped,  and  need  not 
spread. 

Because  every  one  may  and  should  help  stop  it. 

Because  already  there  is  change  for  the  better.  The  number 
of  deaths  from  consumption  is  growing  less.  Twenty  years 
ago  there  were  many  more  deaths  in  proportion  to  the  popu- 
lation than  now. 

If  the  tuberculosis  death-rate  of  1886  had  been  maintained 
the  first  nine  months  of  1902,  four  thousand  more  persons  in 
Manhattan  and  the  Bronx  would  have  died  of  tuberculosis  than 
actually  died  in  these  months. 

Could  anything  be  found  more  inspiring,  more  plainly  in- 
dicative of  the  need  for  extending  the  work  against  this  disease? 

HOW   FIGHT   IT? 

By  remembering  these  five  points  about  the  enemy : 

I.  People  are  seldom  born  with  consumption. 

II.  It  is  caused  by  a  very  small  living  thing  whose  name  is 
"bacillus  tuberculosis." 

263 


III.  This  living  thing  comes  from  the  sick  person  through 
the  spit.  Sometimes  millions  are  coughed  up  and  spit  out  in 
a  single  day  by  one  consumptive  person. 

IV.  This  spit  may  dry,  and  the  germs  mix  with  the  dust, 
float  in  the  air,  and  settle  on  the  walls  or  in  the  carpets. 

V.  They  are  then  breathed  in  and  settle  in  the  throat  and 
lungs,  causing  consumption  of  those  parts. 

HOW    FIGHT   IT? 
By  remembering  these  five  points  about  the  body : 

I.  Your  body  can  resist  these  germs,  so  that  they  will  not 
spread  and  cause  consumption. 

II.  If  your  body  is  weak  it  may  not  be  able  to  resist  them. 

III.  Your  body  may  become  weakened.  How?'  By  strong 
drink,  which  is  one  of  the  best  helpers  the  germs  have.  By 
other  forms  of  dissipation.  By  too  little  food,  air,  and  light. 
By  the  grip,  typhoid  fever,  pneumonia,  bronchitis,  and  some- 
times a  simple  cold. 

IV.  Keep  your  body  strong,  so  that  you  can  resist  the 
germs.  How?  Be  in  the  open  air  as  much  as  possible.  Drink 
plenty  of  pure  water.  Keep  early  hours.  Sleep  eight  hours 
out  of  the  twenty-four.  Live  as  regular  a  life  as  possible;  eat 
plain  good  food ;  see  that  the  bow^els  move  freely  every  day. 
Consult  a  doctor  if  you  have  a  cough,  or  are  run  down,  or  if 
you  cannot  stand  as  much  work  as  you  could  formerly. 

V.  Do  not  spit  yourself  or  allow  your  consumptive  friends 
to  spit  on  the  floor,  carpet,  stove,  wall,  or  street,  or  anywhere 
except  in  a  cup  or  spittoon  for  that  purpose.  This  cup  should 
contain  water  so  that  the  matter  will  not  dry.  When  not  at 
home,  or  in  a  place  where  a  spittoon  cannot  be  used,  carry  little 
pieces  of  tissue  paper,  and  after  use  burn  them. 

Tell  your  friends  that  consumption  is  one  of  the  oftenest 
cured  of  all  chronic  diseases,  and  can  be  cured  in  nearly  all 
cases,  but  it  must  be  taken  very  early. 

Are  you  interested?  If  you  wish  to  read  more  on  this  im- 
portant matter,  write  to  the  Charity  Organization  Society,  105 
East  22d  Street,  New  York,  for  information. 

264 


Appendix  12 

CIRCULAR    ISSUED    BY   THE    DEPART- 
MENT OF  HEALTH 

PRINTED     IN     ENGLISH     AND,    ON     THE     REVERSE     SIDE,     IN     GERMAN, 
ITALIAN,    YIDDISH,    CHINESE,    RUSSIAN 


365 


Issued  by  the  Department  of  Health  for  the  Committee  on  the  Prevention  of 

Tuberculosis  of  the  Charity  Organization  Society,  No.  105 

East  Twenty-second  Street 


CONSUMPTION    IS  A  PREVENTABLE   AND 
CURABLE    DISEASE 

INFORMATION  FOR  CONSUMPTIVES  AND  THOSE  LIVING 
WITH  THEM 

Department  of  Health,  southwest  corner  Fifty-fifth  Street  and  Sixth  Avenue, 

New  York. 

Consumption  is  Chiefly  Caused  by  the  Filthy  Habit  of  Spitting 

Consumption  is  a  disease  of  the  lungs,  which  is  taken  from 
others,  and  is  not  simply  caused  by  colds,  although  a  cold  may 
make  it  easier  to  take  the  disease.  It  is  caused  by  very  minute 
germs,  which  usually  enter  the  body  with  the  air  breathed. 
The  matter  which  consumptives  cough  or  spit  up  contains  these 
germs  in  great  numbers — frequently  millions  are  discharged  in 
a  single  day.  This  matter,  spit  upon  the  floor,  wall,  or  else- 
where, dries  and  is  apt  to  become  powdered  and  float  in  the  air 
as  dust.  The  dust  contains  the  germs,  and  thus  they  enter 
the  body  with  the  air  breathed.  This  dust  is  especially  likely 
to  be  dangerous  within  doors.  The  breath  of  a  consumptive 
does  not  contain  the  germs  and  will  not  produce  the  disease. 
A  well  person  catches  the  disease  from  a  consumptive  only  by 
in  some  way  taking  in  the  matter  coughed  up  by  the  con- 
sumptive. 

Consumption  can  often  be  cured  if  its  nature  be  recognized 
early  and  if  proper  means  be  taken  for  its  treatment.  In  a 
majority  of  cases  it  is  not  a  fatal  disease. 

It  is  not  dangerous  to  live  with  a  consumptive,  if  the  matter 
coughed  up  by  him  be  promptly  destroyed.  This  matter 
should  not  be  spit  upon  the  floor,  carpet,  stove,  wall,  or  side- 

267 


walk,  but  always,  if  possible,  in  a  cup  kept  for  that  purpose. 
The  cup  should  contain  water  so  that  the  matter  will  not  dry, 
or  better,  carbolic  acid  in  a  five  per  cent  watery  solution  (six 
teaspoonfuls  in  a  pint  of  water).  This  solution  kills  the  germs. 
The  cup  should  be  emptied  into  the  water-closet  at  least  twice 
a  day,  and  carefully  washed  with  boiling  water. 

Great  care  should  be  taken  by  consumptives  to  prevent  their 
hands,  face,  and  clothing  from  becoming  soiled  with  the  matter 
coughed  up.  If  they  do  become  thus  soiled,  they  should  be 
at  once  washed  with  soap  and  hot  water.  Men  with  consump- 
tion should  wear  no  beards  at  all,  or  only  closely  cut  mous- 
taches. When  consumptives  are  away  from  home,  the  matter 
coughed  up  should  be  received  in  a  pocket  flask  made  for  this 
purpose.  If  cloths  must  be  used,  they  should  be  immediately 
burned  on  returning  home.  If  handkerchiefs  be  used  (worth- 
less cloths,  which  can  be  at  once  burned,  are  far  better),  they 
should  be  boiled  at  least  half  an  hour  in  water  by  themselves 
before  being  washed.  When  coughing  or  sneezing,  small 
particles  of  spittle  containing  germs  are  expelled,  so  that  con- 
sumptives should  always  hold  a  handkerchief  or  cloth  before 
the  mouth  during  these  acts ;  otherwise,  the  use  of  cloths  and 
handkerchiefs  to  receive  the  matter  coughed  up  should  be 
avoided  as  much  as  possible,  because  it  readily  dries  on  these, 
and  becomes  separated  and  scattered  into  the  air.  Hence, 
when  possible,  the  matter  should  be  I'eceived  into  cups  or  flasks. 
Paper  cups  are  better  than  ordinary  cups,  as  the  former  with 
their  contents  may  be  burned  after  being  used.  A  pocket  flask 
of  glass,  metal,  or  pasteboard  is  also  a  most  convenient  re- 
ceptacle to  spit  in  when  away  from  home.  Cheap  and  con- 
venient forms  of  flasks  and  cups  may  be  purchased  at  many 
drug  stores.  Patients  too  weak  to  use  a  cup  should  use  moist 
rags,  which  should  at  once  be  burned.  If  cloths  are  used  they 
should  not  be  carried  loose  in  the  pocket,  but  in  a  waterproof 
receptacle  (tobacco  pouch),  which  should  be  frequently  boiled. 
A  consumptive  should  never  swallow  his  expectoration. 

A  consumptive  should  have  his  own  bed,  and,  if  possible,  his 
own  room.     The  room  should  always  have  an  abundance  of 

268 


fresh  air — the  window  should  be  open  day  and  night.  The 
patient's  soiled  wash-clothes  and  bed-linen  should  be  handled 
as  little  as  possible  when  dry,  but  should  be  placed  in  water 
until  ready  for  washing. 

If  the  matter  coughed  up  be  rendered  harmless,  a  consump- 
tive may  frequently  not  only  do  his  usual  work  without  giving 
the  disease  to  others,  but  may  also  thus  improve  his  own  con- 
dition and  increase  his  chances  of  getting  well. 

Whenever  a  person  is  thought  to  be  suffering  from  con- 
sumption, the  Department  of  Health  should  be  notified  and  a 
medical  inspector  will  call  and  examine  the  person  to  see  if  he 
has  consumption,  providing  he  has  no  physician,  and  then,  if 
necessary,  will  give  proper  directions  as  to  treatment. 

Rooms  which  have  been  occupied  by  consumptives  should 
be  thoroughly  cleaned,  scrubbed,  whitewashedj  painted,  or 
papered  before  they  are  again  occupied.  Carpets,  rugs,  bed- 
ding, etc.,  from  rooms  which  have  been  occupied  by  consump- 
tives, should  be  disinfected.  Such  articles,  if  the  Department 
of  Health  be  notified,  will  be  sent  for,  disinfected,  and  returned 
to  the  owner  free  of  charge,  or,  if  he  so  desire,  they  will  be 
destroyed. 

When  consumptives  move  they  should  notify  the  Department 
of  Health. 

Consumptives  are  warned  against  the  many  widely  advertised 
cures,  specifics,  and  special  methods  of  treatment  of  consumption. 
No  cure  can  be  expected  from  any  kind  of  medicine  or  method, 
except  the  regularly  accepted  treatment,  which  depends  upon  pure 
air,  an  out-of-door  life,  and  nourishing  food. 

Persons  desiring  additional  information  or  assistance  should 
apply  to  the  Department  of  Health,  55th  Street  and  Sixth 
Avenue,  New  York,  or  the  Charity  Organization  Society,  No. 
105  East  22d  Street. 

By  order  of  the  Board  of  Health, 

Ernst  J.  Lederle,  Ph.D., 
President. 

Hermann  M.  Biggs,  M.D., 
Medical  Officer. 

269 


Appendix   13 

A  MUNICIPAL  SANATORIUM  FOR 
CONSUMPTIVES 

By  RENWICK,   ASPINWALL,   &  OWEN 


271 


A  MUNICIPAL  SANATORIUM  FOR  CONSUMPTIVES 

TWENTY-FIVE  years  ago  mankind  stood  face  to  face  with 
the  great  scourge  tuberculosis,  hopeless  and  helpless.  Its  cause 
was  unknown,  its  onset  was  so  insidious  that  the  fate  of  its 
victims  was  commonly  sealed  while  yet  the  nature  of  their 
malady  was  undiscovered.  Preventive  measures  were  want- 
ing; the  shadow  of  a  sorrowful  belief  in  hereditary  taint  lay 
heavy  upon  many  families;  medical  treatment  seemed  of 
doubtful  value.  The  task  of  the  physician  was  chiefly  to  lead 
the  hopeless  as  gently  as  might  be  to  their  rest. 

To-day  we  know  the  cause  of  tuberculosis  and  the  exact 
modes  of  its  acquirement.  It  can  be  detected  in  its  earliest 
stages,  while  yet  the  hope  of  cure  is  brightest.  We  know  to- 
day just  how  the  germs  pass  to  the  well  from  those  already 
stricken,  and  how  by  the  most  simple  and  obvious  measures  of 
individual  and  public  cleanliness  the  roll  of  fresh  victims  may 
be  at  once  reduced.  We  know  to-day  that  not  to  hereditary 
taint  but  to  household  infection  is  due  the  appalling  destruc- 
tion of  families  by  this  sinister  disease.  The  physician  of  to- 
day is  in  command  of  such  forces  of  healing  as  promise  cure  in 
many  cases  if  the  sufferers  can  be  early  and  properly  cared  for 
where  rest  and  food  and  fresh  air  and  sunshine  are  available. 

But  the  appalling  death-rate  from  tuberculosis  continues. 
It  is  a  little  lowered  here  and  there  it  is  true,  but  the  disease 
still  affects  wellnigh  one-half  of  the  whole  human  race,  causes 
the  death  of  fully  one-tenth  of  all  who  pass  away  in  the  United 
States,  and  kills  about  one-third  of  those  who  perish  between 
the  ages  of  fifteen  and  forty-five. 

273 


The  reasons  for  the  continuance  of  this  malady  and  the  un- 
told misery  and  suffering  which  gather  about  it,  are  threefold : 
— first,  the  people  at  large  do  not  understand  the  ways  in 
which  the  disease  is  spread  and  are  ignorant  of  the  simple 
measures  for  its  avoidance;  second,  many  are  careless  or  in- 
different to  the  risks  of  sanitary  uncleanliness  ;  third,  the  facili- 
ties for  the  care  of  the  poor  and  the  friendless  who  are  stricken 
are  utterly  inadequate.  Thus  the  larger  proportion  of  the  vic- 
tims of  tuberculosis  are  hopeless  in  sight  of  the  hope  which 
science  holds  out  to  all.  And  thus  each  uncared  for  sufferer 
is  left  to  become  a  source  of  fresh  infection  to  his  fellows. 

These  are  the  main  reasons  why  the  preventable  disease 
tuberculosis,  after  a  quarter  of  a  century  of  saving  knowledge, 
is  still  the  scourge  of  the  human  race. 

How  shall  general  enlightenment  be  secured?  How  shall 
the  careless  and  the  indifferent  be  induced  to  conform  to 
the  plain  requirements  of  sanitary  cleanliness?  How  shall  the 
stricken  poor  and  the  friendless  be  offered  the  hope  for  re- 
covery which  humanity  urges?  These  are  problems  which 
each  community  must  solve  for  itself. 

Boards  of  Health  can  do  much  in  informing  the  public,  in 
enforcing  general  sanitary  regulations,  in  disinfecting  rooms 
and  dwellings  in  which  consumptives  have  lived  and  died,  and 
in  gathering  statistics  of  the  disease.  Beyond  this  they  can 
do  little,  and  this  leaves  some  of  the  main  things  undone.  The 
New  York  City  Board  of  Health  has  been  especially  effective 
in  accomplishing  what  its  scope  and  facilities  have  permitted 
to  suppress  this  scourge.  But  still  five  thousand  lives  are 
sacrificed  each  year  in  this  city  alone  to  this  preventable 
disease. 

The  Charity  Organization  Society  of  New  York  has  now 
undertaken  to  meet  the  critical  situation  in  this  city  by  the 
establishment  of  a  permanent  Committee  on  Tuberculosis. 

To  remedy  the  two  first  causes  mentioned  above,  the  Com- 
mittee has  endeavored  to  enlighten  the  public  by  lectures  and 
through  the  distribution  of  pamphlets  setting  forth  the  facts 
about  the  disease.     To  aid  in  the  solving  of  the  problem  aris- 

274 


ing  from  the  third  cause,  the  Committee  has  now  had  prepared 
plans  for  a  municipal  sanatorium  for  the  care  of  consumptives, 
and  submitted  them  to  the  Health  Department  of  the  City  of 
New  York. 

Under  the  provisions  of  Chapter  327,  Laws  of  1900,  the  city- 
is  empowered  to  establish,  equip,  and  maintain,  outside  of  its 
corporate  limits,  a  hospital  or  hospitals  for  the  regular  treat- 
ment of  pulmonary  tuberculosis,  provided  the  Board  of  Health 
shall  deem  it  necessary. 

The  plans  are  described  in  the  following  letter  of  the  archi- 
tects : 

"New  York,  February  20,  1903. 

"To  the  Committee  on  the  Prevention  of  Tuberculosis  of  the 
Charity  Organization  Society  of  the  City  of  New  York : 

"Gentlemen:  We  beg  to  hand  you  herewith  plans  for  a 
proposed  municipal  sanatorium  for  the  treatment  of  tubercu- 
losis, to  be  located  in  the  country  near  the  city  of  New  York. 
These  plans  are  based  upon  the  suggestions  made  to  us  by 
your  Committee,  and  upon  our  experience  gathered  in  the 
actual  building  of  the  Adirondack  Cottage  Sanatorium  at 
Saranac  Lake,  the  Stony  Wold  Sanatorium  at  Lake  Kushaqua, 
and  on  the  study  of  the  proposed  sanatorium  at  Denver,  Colo- 
rado. Site. — As  no  site  has  yet  been  chosen  for  this  sana- 
torium, we  have  been  obliged  to  assume  the  natural  conditions 
of  the  ground  and  have  adopted  a  site  giving  a  southwestern 
exposure  for  the  pavilions,  with  a  protecting  hill  to  the  north- 
east shielding  the  buildings  from  the  most  violent  storms. 
This  condition  is  shown  in  our  bird's-eye  view  of  the  institu- 
tion. This  site  gives  sunlight  to  the  patients  in  the  pavilions 
all  day. 

"As  you  drive  toward  the  sanatorium  on  the  public  roads 
you  would  first  have  a  general  view  of  the  pavilions  above  you 
on  the  heights.  The  private  driveway  of  the  institution  circling 
around  below  the  pavilions  will  lead  in  a  gradual  ascent  to  the 
administration  building,  giving  a  fine  view  of  the  entire  grounds 
as  you  approach  the  latter  building.     The  drive  will  continue 

275 


around  the  administration  building  and  back  to  the  central 
building,  passing  over  the  boiler-house,  which  will  be  partly 
underground,  allowing  coal  to  be  dropped  directly  into  the 
bunkers  beneath.  From  the  central  building  a  covered  corri- 
dor will  lead  back  to  and  join  with  the  main  corridor  connecting 
all  the  pavilions.  On  the  main  axis  and  directly  back  of  the 
central  building  is  the  large  recreation  hall  and  assembly  room, 
which  also  acts  as  a  general  solarium.  On  the  corridors  con- 
necting the  pavilions  and  midway  between  the  second  and 
third  pavilions  on  each  side  will  be  located  the  small  diet 
kitchens  with  the  small  dining-rooms.  On  this  corridor  will 
also  be  located  the  staircases  leading  from  the  first  to  the 
second  stories.  On  the  transverse  axis  on  a  line  with  the 
boiler-house  will  be  located  the  isolated  pavilions  for  con- 
tagious diseases  one  for  men  and  one  for  women.  On  a  line 
with  the  administration  building  will  be  located  on  one  side 
the  laboratory,  and  on  the  other  the  laundry  building.  The 
boiler-house  and  engine-room  are  located,  as  you  will  notice, 
in  a  central  position,  enabling  the  heat  to  be  distributed  in  a 
rapid'  and  economical  manner  in  all  directions  to  the  various 
buildings.  Electric  light  can  also  be  economically  distributed 
from  this  point.  By  sinking  the  building  below  the  finished 
grade,  carrying  the  main  driveway  over  its  roof,  and  by  treating 
the  main  chimney  in  an  architectural  manner,  the  unsightly 
quality  of  this  type  of  building  is  done  away  with  and  the  great 
advantage  is  gained  of  distributing  heat  and  light  from  a  cen- 
tral point.  By  terracing  the  ground,  windows  may  be  placed 
on  the  side  of  this  building,  affording  light  and  ventilation  to 
the  boiler-  and  engine-room.  The  large  recreation  hall  acts  as 
a  natural  division  between  the  men's  and  women's  portions  of 
the  building.  The  laboratory  and  laundry  buildings  being 
placed  off  to  the  ends  may  be  partially  or  wholly  hidden  by 
trees  and  shrubbery,  but  at  the  same  time  they  will  be  easy  of 
access.  The  camp,  where  the  patients  will  live  in  tents,  will 
be  placed  ofT  to  the  side  as  show^n,  with  the  tents  arranged  in 
streets  with  wide  spaces  and  pleasing  landscape  effects,  and 
with  a  recreation  hall  conveniently  located.     At  the  centre  of 

376 


each  block  of  tents  will  be  placed  a  toilet  and  bath  building 
for  the  block,  with  paths  leading  to  same  and  with  shrubbery 
arranged  to  hide  the  building.  This  camp  may  be  made  very 
attractive  by  proper  arrangement  of  shrubbery,  and  may  also 
give  light  employment  to  the  patients  in  arranging  and  caring 
for  the  grounds  and  gardens. 

"We  have  selected  as  the  style  to  be  followed  in  this  group 
of  buildings  the  Colonial  type,  which  gives  so  homelike  and 
cheerful  an  effect  where  used.  At  the  same  time  it  is  very 
economical  and  simple,  being  inexpensive  and  easily  followed 
out  in  execution.  The  general  treatment  would  be  in  red 
brick  with  white  stone  trimmings,  with  slate  roofs.  The  cor- 
ridors connecting  the  various  buildings,  the  solariums  on  the 
ends  of  the  pavilions,  and  the  dome  of  the  large  recreation 
hall  being  constructed,  as  far  as  possible,  of  glass.  This  treat- 
ment should  insure  an  interesting,  cheerful,  and  uniform  group 
seen  with  a  setting  of  green  foliage  and  natural  scenery. 

"The  interior  arrangement  and  finish  of  the  various  build- 
ings would  naturally  be  up  to  the  standard  of  the  latest  hos- 
pital construction.  It  is  not  contemplated  to  construct  the 
buildings  fireproof,  because  of  the  cost,  and  the  fact  that  the 
buildings  are  only  two  stories  high.  The  plastering  to  be  done 
throughout  in  hard  finish  with  all  corners,  both  of  walls  and 
ceilings,  rounded,  and  with  rounded  corners  at  all  windows 
and  doors.  The  finished  floors  to  be  of  the  latest  fireproof 
composition  construction  with  sanitary  bases.  The  doors  to 
be  flush  paneled  throughout,  the  trim  to  be  without  mouldings 
or  corners.  All  buildings  to  be  provided  with  stand  pipes  and 
fire  plugs  on  all  floors,  at  least  one  of  these  to  each  ward. 
Wall  cuspidors  to  be  placed  in  the  dining-hall  for  patients,  and 
in  the  corridors  connecting  the  wards  at  intervals  of  every 
eighty  feet ;  these  cuspidors  to  be  supplied  with  running  water. 
Sanitary  drinking  fountains  also  to  be  supplied  in  the  same 
manner,  but  at  different  locations. 

"The  administration  building  (see  Drawings  A,  B,  and  D") 
will  have  a  large  hall  on  the  first  floor  running  through  to  the 
rear  of  the  building,  with  halls  at  right  angles  leading  to  the 

277 


wings  of  the  building.  On  the  right  of  the  entrance  is 
the  business  office,  the  superintendent's  office  opening  from 
it.  Next  to  the  superintendent's  office  is  the  board  room. 
On  the  left  as  you  enter  is  the  reception  room.  On  the  left 
also  is  the  superintendent's  suite,  consisting  of  a  sitting-room, 
dining-room,  pantry,  two  bed-rooms,  and  a  bath.  On  the  left 
is  also  the  suite  for  the  assistant  resident  physicians,  consisting 
of  a  sitting-room,  two  bed-rooms,  and  a  bath.  On  the  right  of 
the  main  hall  are  the  apartments  of  the  resident  physician, 
the  director  of  laboratories,  and  the  apothecary,  together  with 
their  baths.  On  the  second  floor  of  the  administration  build- 
ing will  be  the  apartments  of  the  head  nurse,  two  women 
physicians,  women  nurses,  and  three  guest-rooms  for  members 
of  the  board,  or  others  who  visit  the  institution  overnight. 
On  the  third  story  will  be  the  majority  of  the  nurses.  We 
have  provided  accommodations  for  forty-four  nurses  in  this 
building,  allowing  two  nurses  to  a  room,  and  have  provided  a 
sitting-room,  library,  and  ample  bathing  accommodations  for 
them. 

"The  central  building  (see  Drawings  A,  C,  D)  will  contain, 
on  the  first  floor  to  the  right  as  you  enter,  the  doctor's  ante- 
room and  office,  the  office  of  the  head  nurse,  toilet  rooms, 
and  the  staff  and  nurses'  dining-rooms,  with  pantries  for  serv- 
ing same.  On  the  left  of  the  main  hall  is  the  drug-room,  the 
dining-room  for  male  patients,  and  pantries  for  serving.  A 
separate  entrance  to  the  dining-rooms  from  the  grounds  is 
shown,  with  lavatories  and  coat  room,  so  that  patients  living 
in  the  tents  may  enter  direct  to  their  meals.  A  stairway  leads 
to  the  women's  dining-room  on  the  second  floor.  On  the 
second  floor  (Drawing  E)  and  over  the  dining-room  below  is 
the  women's  dining-room  of  the  same  size  and  with  equal 
serving-rooms  and  cloak  and  toilet  facilities.  Ample  dumb- 
waiters are  provided  from  the  kitchen  below.  In  the  other 
wing  on  this  floor  are  the  women  servants'  dormitories  and 
bath-rooms.  An  apartment  is  provided  for  the  matron  so  that 
she  may  have  supervision  of  the  servants.  In  the  basement 
(Drawing  C)  is  the  great  kitchen  with  its  complete  cooking  and 

378 


serving  plant,  including  sterilizing  and  washing  steam  vats  for 
dishes,  knives,  forks,  etc.,  the  bake  shop  and  ovens,  butcher 
shop,  storerooms  for  various  stores,  the  office  of  the  house- 
keeper, the  pantry  for  serving  the  dining-rooms  above,  toilets 
and  the  dining-rooms  for  male  and  female  servants. 

"It  is  proposed  to  make  of  the  recreation  hall  (Drawings 
A  and  D)  a  general  assembly  and  meeting  room  in  which 
religious  services,  lectures,  musicals,  amateur  theatricals,  etc., 
may  be  held  and  all  general  social  intercourse  of  the  patients 
take  place.  A  stage  may  be  erected  at  the  end  of  the  circular 
apse  for  all  these  purposes.  By  constructing  the  dome  of 
glass,  this  hall  may  also  be  used  as  a  solarium  during  the  day. 
Toilet  facilities  are  provided  for  both  sexes.  The  windows  in 
this  hall  are  all  open  down  to  the  floor,  affording  access  to  the 
terrace  surrounding  the  hall  and  ease  in  emptying  the  room 
in  case  of  necessity.  Opening  off  the  corridor  leading  to  the 
central  building  will  be  the  operating  and  throat  room,  together 
with  a  lift  to  take  patients  from  one  floor  level  to  the  other. 

"Extending  on  either  side  of  the  main  axis  and  connected 
by  the  corridors  are  the  pavilions  for  the  patients  (Drawings 
A  and  D).  They  are  two  stories  in  height  and  arranged  in 
fan-like  form  for  the  purpose  of  giving  each  building  a  maxi- 
mum of  sunlight.  The  first  pavilion  on  either  side  of  the 
recreation  hall  has  been  divided  up  into  single  rooms,  sixteen 
on  each  floor,  with  the  solarium  at  the  south  end.  On  each 
floor  is  the  nurse's  room  with  lavatory  and  clothes  room,  and 
on  the  opposite  side  of  the  corridor  a  housemaid's  room, 
linen  room,  and  toilet  and  bath-room  for  the  ward,  contain- 
ing a  bath-tub,  two  showers,  three  urinals,  three  closets,  and 
four  basins  for  men,  and  two  baths,  one  shower,  three  closets, 
and  four  basins  for  women.  The  ward  pavilions,  of  which 
there  are  three  on  either  side  of  the  separate  room  pavilions, 
will  each  accommodate  thirty-two  patients,  sixteen  on  each 
floor,  and  have  the  same  toilet,  bath,  clothes,  linen,  and  nurses' 
accommodations  as  the  separate  room  pavilions.  An  allow- 
ance of  1300  cubic  feet  of  air  per  patient  has  been  made. 
These  pavilions  are  also  arranged  with  a  solarium  at  the  end 

279 


of  each  ward  so  that  a  patient  in  bed  may  be  wheeled  directly 
into  the  solarium,  and  those  patients  occupying  the  ground 
floor  may  be  wheeled  directly  from  the  ward  out  on  the 
veranda.  Movable  screens  would  be  provided  on  these 
verandas  to  shut  off  draughts. 

"At  the  centre  of  each  group  of  pavilions  is  located  a  two- 
story  diet  kitchen  (Drawings  A  and  D)  to  serve  the  four  wards 
on  each  floor  nearest  it,  with  all  proper  equipment;  and  on  the 
opposite  side  of  the  corridor  is  located  a  small  dining-room  for 
the  patients  who,  while  able  to  be  out  of  bed,  are  yet  unable 
to  go  to  the  main  dining-room.  Food  may  be  taken  to  these 
diet  kitchens  from  the  main  kitchen  and  storeroom  without 
passing  through  the  main  corridors,  either  by  the  paths  shown, 
or  through  the  basement  corridor  beneath  the  main  corridors. 

"Two  isolation  pavilions  (Drawings  A  and  D)  are  provided 
on  the  grounds,  one  for  male  and  one  for  female  patients,  each 
containing  two  rooms  for  patients,  bath,  nurses'  rooms,  and 
closets.  These  buildings  may  be  used  for  any  cases  of  con- 
tagious or  other  diseases  which  it  may  be  desired  to  segregate. 

"The  laundry  building  (Drawings  A  and  D)  is  located  on  the 
right  of  the  administration  building,  and  will  contain  a  com- 
plete modern  laundry  equipment  run  by  electricity  and  with 
all  proper  steam  connections,  a  disinfecting  plant,  assorting 
room,  storeroom,  and  clean-clothes  room  on  the  main  floor. 
The  second  floor  will  be  divided  into  two  rooms  for  the  male 
servants,  with  a  sitting-  and  bath-room  for  them. 

"The  bacteriological  and  pathological  laboratory  (Drawings 
A  and  D)  is  situated  on' the  left  of  the  administration  building 
and  contains  in  the  basement  the  morgue,  cold  storage,  and 
storerooms.  On  the  main  floor  will  be  the  pathological  labora- 
tory, the  office,  and  the  record  room,  the  autopsy  room,  with 
lift  to  communicate  with  morgue,  storeroom,  and  toilet  rooms. 
On  the  second  floor  will  be  the  bacteriological  laboratory  with 
its  attendant  rooms  and  office  for  the  director  of  laboratories. 

' '  We  have  shown  a  scheme  for  the  arrangement  of  tents  with 
alternate  plans,  either  one  of  which  may  be  preferred  (Drawings 
E,  F,  and  G).     In  our  tent  plan  we  have  endeavored  to  pro- 

280 


Second  Floor  Plan 


Third  Floor  Plan 

Administration  Builxung 

FOR  A  ^/yJ^iiii:  a^ 

Municipal  Sanatorium  submitted  to  The     ''^Z  ^/^  '^^"^ 
Board  of  He^^lth  bt  t^e  Committee  on  the 
Prevention  gf  Tuberculosis  of  THe 
Charity  Organization  Society 


Basement  Puan 


Second  F"Loor  Plan 
Central  Building 

Municipal  Sanatorium  submitted  to  The    , ,    ^.  ^       - 
Board  or  Health  by  the  Committee  on  the '^"^/^  ^^^-.^h^. 
Prevention  of  Tuberculosis  of  The 
Charity  Organization  Society 


© 


duce  an  economical  and  at  the  same  time  attractive  lay-out. 
The  tents  are  arranged  in  squares  with  a  large  recreation  hall 
in  the  centre,  with  broad  streets  and  avenues  radiating  from 
this  building.  At  the  centre  of  each  square  is  located  a  toilet 
and  bath  building  properly  hidden  by  shrubbery.  Drawing  E 
represents  the  concentrated  plan  with  a  capacity  of  112  tents, 
each  tent  measuring  14  xi6  feet,  with  an  8-foot  platform. 
This  scheme  covers  an  area  of  8f  acres.  Drawing  F  repre- 
sents the  extended  plan  of  112  tents,  covering  an  area  of 
261  acres.  Drawing  G  represents  the  extended  plan  of  120 
tents,  covering  35  acres.  In  scheme  G  the  tents  will  be  35 
feet  apart  and  in  the  concentrated  scheme  25  feet  apart.  In 
the  extended  schemes  the  arrangement  of  the  toilet  and  bath 
buildings  and  recreation  hall  has  been  varied  to  suit  the  plan. 
Guard  houses  have  been  provided  for  the  orderlies  in  charge 
at  points  which  command  the  streets  and  where  they  may 
have  direct  telephonic  connection  with  the  central  group  of 
buildings.  Each  tent  will  be  provided  with  an  electric  light 
and  fixed  wardrobe  for  clothing  as  well  as  the  necessary  furni- 
ture. It  is  desirable,  if  possible,  to  have  rubble-stone  masonry 
foundations  under  the  tents  and  platforms  proper.  The  con- 
struction of  the  tents  would  be  preferably  of  planed  timber 
bolted  together  at  the  joints,  as  per  diagram  shown  on  Drawing 
E,  and  the  frame  should  be  kept  well  painted.  The  care  of 
the  lawns  and  flower-plots  between  the  tents  should  afford 
light  and  pleasant  work  to  the  patients. 

"As  will  be  noted  by  the  plan,  the  location  of  the  power- 
house is  midway  between  the  various  buildings,  and  is  so 
arranged  that  power  and  light  can  be  distributed  most  eco- 
nomically to  all  of  the  buildings  from  a  central  point.  It  is 
proposed  to  heat  all  of  these  various  buildings  by  means  of 
direct  radiation,  either  steam  or  hot  water  being  used  to  con- 
vey the  heat  from  the  power-house  to  the  various  buildings. 
It  is  intended  to  use  the  exhaust  steam  from  the  electric  light 
engines  to  furnish  the  heat  as  far  as  it  will  go,  and  to  make  up 
the  deficiency  by  using  live  steam  from  the  boilers.  In  this 
way  the  most  economical  system  in  coal  consumption  is  ob- 

281 


tained.  The  boiler  plant  will  consist  of  three  horizontal  tubular 
boilers,  each  of  125-horse-power  capacity,  properly  set  in  brick- 
work, with  all  necessary  connections.  It  is  estimated  that  the 
heating  and  laundry  work  will  require  about  225  horse-power, 
and  this  power  includes  that  necessary  for  the  electric  light 
engines.  It  is  deemed  best  to  install  a  surplus  amount  of 
power  divided  up  into  three  units  so  that  there  will  at  all  times 
be  one  spare  unit,  which  may  be  laid  off  for  any  necessary  re- 
pairs. The  heating  will  be  accomplished  by  means  of  direct 
radiators  and  coils  located  in  the  various  rooms,  and  the  pipes 
for  distributing  this  heat  will  be  laid  in  underground  conduits 
all  properly  protected  against  any  undue  loss  of  heat  in  trans- 
mission. All  the  condensation  from  the  various  buildings  will 
be  returned  direct  to  the  boiler-house,  so  that  there  will  be  no 
loss,  and  any  condensation  will  be  used  over  again.  There 
will  be  required  approximately  about  20,000  square  feet  of 
radiators  in  the  various  buildings. 

"It  is  proposed  to  install  a  complete  lighting  plant  in  the 
boiler-house.  The  plant  will  consist  of  two  50-kilowatt  direct- 
connected  units  operated  at  125  volts,  and  one  25-kilowatt 
direct-connected  unit  operated  at  125  volts.  These  machines 
will  be  connected  to  high-speed  engines,  requiring  from  eighty 
to  ninety  pounds  steam  pressure,  the  exhaust  being  used  for 
heating.  A  complete  marble  sv/itchboard  with  all  the  requisite 
feeders  for  distributing  the  current  to  the  buildings  will  be 
provided,  the  feeders  being  run  in  conduits  as  an  underground 
system.  A  system  of  power  distribution  for  the  kitchen  and 
laundry  buildings  will  also  be  provided,  run  in  the  same  man- 
ner as  the  lighting  feeders.  Approximately  twenty  arc  lamps 
of  low-tension  type,  arranged  on  ornamental  poles,  will  be 
located  on  the  grounds;  all  the  wiring  for  feeding  same  being 
included  in  the  underground  system.  The  various  buildings 
will  be  wired  for  electric  lighting  and  power  where  required  for 
a  total  of  approximately  1200  sixteen  c.  p.  lamps,  including 
the  tents  and  outbuildings.  The  wiring  throughout  the  build- 
ing will  be  run  according  to  the  latest  methods,  using  steel 
conduits,  slate  panel  boards,  and  the  entire  system  being  fire- 

282 


proof.  It  is  further  proposed  to  arrange  a  system  of  telephones 
for  connecting  the  various  buildings  and  guard  houses  to  a 
central  station  in  the  administration  building.  This  system 
will  be  of  the  latest  type,  the  wiring  all  being  run  in  circuits 
so  as  to  be  easily  removable.  The  necessary  bell  and  annunci- 
ator system  for  the  ofificial  portions  of  the  hospital  will  be 
provided,  using  the  best  grades  of  apparatus,  and  furnishing 
a  complete  method  of  communication.  A  watchman's  clock 
system,  the  register  being  located  in  the  administration  build- 
ing, and  so  arranged  that  the  watchman,  in  making  his  rounds 
of  the  building,  records  his  presence  at  regular  intervals,  is 
contemplated,  using  the  very  latest  apparatus  for  this  work. 
In  short,  a  complete  electric  system,  such  as  is  required  for  the 
most  modern  form  of  hospital  building,  will  be  arranged  for. 

"At  present  it  is  proposed  to  build  the  central  building,  the 
boiler-house,  four  pavilions  with  their  corridors,  the  laboratory 
building,  and  the  laundry,  together  with  the  tents  and  their 
attendant  toilet  and  recreation  buildings.  This  will  give  a  ca- 
pacity of  224  patients  in  the  tents  and  128  in  the  four  pavilions, 
making  a  total  of  352  patients.  It  will  be  absolutely  necessary 
to  have  the  central  building,  boiler-house,  the  laboratory,  and 
laundry  buildings  in  order  to  supply  the  wants  and  necessities 
of  the  patients  living  in  the  tents.  These  necessary  buildings 
can  be  arranged  to  hold  temporarily  all  of  the  departments 
which  will  ultimately  be  housed  in  the  administration  building, 
owing  to  the  smaller  number  of  people  to  be  employed  at  first. 

"The  cost  of  building  a  sanatorium  of  this  nature  depends 
to  a  certain  extent  on  the  natural  conditions  at  the  site,  the 
locality,  and  the  condition  of  the  building  industry  in  general 
at  the  present  time.  By  the  natural  conditions  of  the  site  we 
mean  its  accessibility  to  a  railroad  or  water  base,  the  distance 
required  in  hauling,  the  grades,  natural  surroundings,  etc.  By 
the  locality  we  mean  the  distance  from  New  York  City,  the 
abundance  of  local  labor,  ability  of  local  contractors,  and 
the  labor  situation.  By  the  last  condition,  we  mean  that  at  the 
present  time  all  building  is  very  expensive,  and  there  seems 
very  little  chance  of  a  decrease  in  the  cost  of  materials,  etc. 

283 


In  making  our  estimate  of  cost  we  have  assumed  that  at  present 
the  intention  would  be  to  erect  the  tents  as  shown,  together 
with  the  buildings  in  the  tent  group,  and  with  the  build- 
ings of  the  central  group  necessary  to  make  a  working  sana- 
torium. These  buildings  would  be  the  central  building,  the 
boiler-house,  the  laboratory  building,  the  laundry  building, 
four  pavilions,  and  the  necessary  connecting  corridors.  A 
careful  estimate  of  the  cost  of  the  above,  made  with  as  close 
a  reference  to  the  conditions  mentioned  as  it  is  possible  to 
assume,  would  be  $278,000.  The  cost  of  the  balance  of  the 
buildings  in  the  central  group,  shown  in  our  complete  lay-out, 
would  be  $252,000,  making  a  total  cost  of  $530,000. 

If  it  is  considered  practicable  and  desirable,  two  of  the  four 
pavilions  proposed  to  be  erected  at  once,  might  be  omitted, 
making  a  saving  of  $59,000,  which  would  reduce  the  initial 
cost  to  $219,000.  We  summarize  below  the  cost  and  capacity 
of  the  sanatorium  on  the  basis  above  stated : 

"If  tents  (112)  are  built  with  two  pavilions  and  the  neces- 
sary central  buildings,  giving  a  capacity  of  288  patients,  the 
cost  will  be  $219,000. 

"If  tents  (112)  are  built  with  four  pavilions  and  the  neces- 
sary central  buildings,  giving  a  capacity  of  352  patients,  the 
cost  will  be  $278,000. 

"If  tents  (112)  are  built  with  eight  pavilions  and  the  com- 
plete group  of  buildings,  giving  a  capacity  of  480  patients,  the 
cost  will  be  $530,000. 

"Respectfully, 
"Renv^ick,  Aspinwall,  &  Owen." 


284 


Appendix  14 

PLANS  FOR  A  MUNICIPAL  SANATORIUM 
FOR  CONSUMPTIVES 

PREPARED    BY 

MESSRS.   HOWELLS  &  STOKES 

ARCHITECTS 


285 


PLANS    FOR    A    MUNICIPAL    SANATORIUM    FOR 
CONSUMPTIVES 

New  York,  May  29,  1903. 

To  the  Committee  on  the  Prevention   of  Tuberculosis,   Charity 

Organization  Society',  105  East  22d  Street,  City. 
Gentlemen: 

We  submit  herewith,  in  accordance  with  your  invitation, 
drawings  for  a  municipal  tuberculosis  sanatorium  to  accommo- 
date 500  patients.  The  plan  comprises:  (i)  an  administration 
building  containing  public  reception  rooms,  doctors'  offices  and 
examination  rooms,  and,  in  a  separate  wing,  a  public  dining- 
hall.  The  basement  of  this  building  contains  kitchens  and 
general  service,  and  the  nurses  and  orderlies  are  accommodated 
in  separate  wings  on  the  second  and  third  floors ;  (2)  the  male 
and  female  wards  accommodating  200  patients,  occupying 
opposite  sides  of  the  plan  and  separated  by  a  low  building 
containing  public  recreation  rooms  and  assembly  hall;  (3)  an 
encampment  accommodating  300  patients;  (4)  necessary  ad- 
juncts, such  as  power  plant,  laboratories,  contagious  wards, 
etc. 

We  have  chosen  and  developed  a  type  of  plan  which,  we 
believe,  permits  of  greater  economy  in  construction,  while  se- 
curing much  more  light,  air,  and  sunshine  and  a  far  better 
outlook  for  the  various  buildings  than  is  possible  in  any  type 
where  the  buildings  are  arranged  in  a  compact  group,  usually 
presenting  but  a  comparatively  small  surface  to  the  sun,  and 
necessarily  overlooking  one  another  in  a  way  to  interfere  seri- 
ously with  privacy  as  well  as  with  a  proper  circulation  of  air. 

287 


The  object  of  close  concentration  is,  of  course,  to  secure 
economy  of  operation  and  service ;  but  a  close  comparison  of 
the  two  types  will,  we  think,  convince  that  the  slightly  in- 
creased distances  to  be  traversed,  and  the  somewhat  greater 
cost  of  the  heating  and  plumbing  systems  in  the  one  which  we 
have  selected,  are  more  than  compensated  for  by  the  greater 
simplicity  of  arrangement,  the  greater  economy  of  general 
construction,  the  better  outlook,  the  greater  amount  of  sun, 
and  the  better  circulation  of  air  which  this  type  permits. 

We  estimate  the  cost  of  the  buildings,  including  the  encamp- 
ment, as  shown  on  our  drawings,  at  about  $407,000,  made  up 
as  follows : 

Six  ward  pavilions  at  $35,000  each,  including  solarium $210,000 

Other  buildings,  including  covered  passageways 117,000 

Heating  system,  including  plant 48,000 

Lighting  system,  including  electric  plant 23,000 

Tents,  including  platforms  and  frames 9,000 

These  figures  are  based  upon  estimates  received  from  reliable 
contractors.  The  cost  of  grading,  planting,  the  building  of 
roads,  paths,  etc.,  would,  of  course,  depend  on  the  nature  of 
the  site.  On  a  comparatively  level  site,  or  a  gentle  slope, 
such  as  is  shown  on  our  drawings,  $50,000  would  probably 
cover  this  item  of  expense. 

The  following  notes  are  offered  in  further  explanation  of 
the  drawings  : 

Cheerfulness  of  immediate  surroundings  and  an  interesting 
and  pleasing  outlook  are  so  important  in  the  treatment  and 
cure  of  tuberculosis  as  to  demand  most  careful  attention  in  the 
design  of  all  buildings  intended  for  the  occupancy  of  tubercu- 
lous patients.  They  are  of  special  importance  in  those  build- 
ings in  which  the  patients  sleep,  and  in  the  recreation  parlors, 
or  solaria,  in  which  the  greater  part  of  their  time  within  doors 
is  spent.  To  this  end,  the  main  wards  or  home-pavilions,  to- 
gether with  their  connecting  solaria,  have  been  placed  in  the 
foreground  of  the  plan  on  a  broad  terrace  with  a  southern  or 
southeastern  exposure,  which  is  supposed  to  command  an  ex- 

288 


m 


.0     ' 

2    ^ 


s^;i 


■■\v 


tended  view,  and  from  which,  as  well  as  from  the  pavilions  and 
solaria,  the  quiet  and  peaceful  view  can  be  fully  enjoyed. 

The  main  pavilions  have  been  divided  into  two  groups  of 
three  pavilions  each — one  group  for  male,  the  other  for  female 
patients.  These  two  groups  are  connected  with  the  other 
buildings  composing  the  main  group  of  the  sanatorium  by 
covered  galleries  which  afford  sufficient  protection  from  in- 
clement weather  but  do  not  appreciably  interfere  with  the  free 
circulation  of  air,  etc. 

In  the  general  design  of  the  buildings  and  in  their  archi- 
tectural treatment  we  have  attempted  to  combine  simplicity, 
economy,  restful  dignity,  and  a  cheerful  aspect. 

The  choice  of  materials  appropriate  for  the  exterior  of  the 
buildings  is  practically  unlimited.  We  have  suggested  in  our 
design  the  use  of  common  brick  covered  with  stucco,  which  is 
a  substantia]  and  economical  form  of  construction  and  can  be 
frequently  whitewashed  with  but  little  expense,  and  red  tile 
or  green  copper  roofs,  which  would  give  a  cheerful  and  cleanly 
appearance.  Hard  plaster  and  the  simplest  hospital  trim  are 
used  throughout  the  buildings. 

The  wards  are  two  stories  in  height,  accommodating  fifty 
patients  on  each  floor. 

All  plumbing  in  connection  with  the  wards  is  concentrated 
in  a  small  two-story  pavilion  connected  to  its  ward  on  each 
floor  by  an  enclosed  passage. 

The  wards  are  eleven  feet  in  height,  and  are  provided,  in 
addition  to  the  ordinary  windows,  with  a  series  of  transoms 
near  the  ceiling  in  the  front  and  rear  walls,  so  arranged  that  a 
free  circulation  of  air  may  always  be  had  without  causing  a 
draught  in  the  lower  portion  of  the  room.  Provision  is  also 
made,  by  means  of  a  movable  sash,  for  a  free  circulation  of  air 
beneath  the  floors  of  the  wards  and  galleries. 

All  heating  and  plumbing  pipes,  electric  light  and  fan  con- 
duits, telephones,  bell  work,  etc.,  are  carried  in  trenches  be- 
neath the  corridors  and  covered  passages. 

A  general  heating  plant  is  provided  for  the  main  group  of 
buildings,  comprising  the  administration  building,  the  recrea- 

389 


tion  buidling,  and  the  ward  pavilions,  the  outlying  buildings 
being  heated  by  small  separate  plants.  With  proper  insula- 
tion, the  loss  of  heat  in  the  farthest  pavilion  involved  by  this 
system  would  be  less  than  one  per  cent.  The  gravity  return 
system  of  hot-water  circulation  is  used. 

Radiators  are  placed  in  open  recesses  under  the  windows. 
These  radiators  are  fixed  by  brackets  to  the  walls  several 
inches  above  the  floor,  and  stand  out  far  enough  to  permit  of 
the  walls  behind  them  being  easily  cleaned. 

Electric  lights  are  provided  throughout ;  also  outlets  for 
movable  electric  fans. 

A  bacterial  sewage  purification  system  of  disposal  is  provided 
at  some  distance  from  the  buildings. 

The  ground  area  actually  covered  by  the  proposed  plan  is 
forty  acres,  although  the  grounds  belonging  to  the  sanatorium 
are  supposed  to  contain  many  times  this  acreage.  Only  that 
portion  of  the  property  which  has  been  formally  treated  is 
shown  in  the  accompanying  plans;  the  remaining  grounds  are 
supposed  to  be  informally  treated  with  wooded  drives  and 
walks,  farm  lands,  etc. 

Respectfully  submitted, 

HowELLS  &  Stokes. 


290 


Appendix  15 

MUNICIPAL  SANATORIUM  FOR  INCIPI- 
ENT CASES  OF  TUBERCULOSIS 

A    REPORT    FROM    THE 

HON.  HOMER  FOLKS, 

COMMISSIONER  OF    THE    DEPARTMENT    OF    PUBLIC    CHARITIES, 

TO  THE    BOARD    OF    ESTIMATE    AND    APPORTIONMENT    OF 

THE    CITY  OF  NEW  YORK,  JULY   15,    1903 


391 


MUNICIPAL   SANATORIUM    FOR   INCIPIENT 
CASES    OF   TUBERCULOSIS 

Department  of  Public  Charities, 

Commissioner's  Office, 

Foot  of  East  26th  Street,  New  York. 

Hon.  Seth  Low, 

Chairman  Board  of  Estimate  and  Apportionment, 
City  Hall,  New  York  City. 

Sir:  On  April  14,  1903,  a  resolution  was  unanimously  passed 
by  the  Board  of  Aldermen  which  became  effective  by  your 
approval  on  April  24th,  as  follows : 

Whereas,  It  has  been  determined  that  tuberculosis  of  the 
lungs,  or  consumption,  is  a  communicable  disease,  and  also 
that  it  can  be  cured,  or  at  least  arrested,  especially  in  its  early 
stages;  and 

Whereas,  It  is  one  of  the  greatest  scourges  of  humanity  in 
this  city,  as  elsewhere ;  and 

Whereas,  The  present  means  at  the  disposal  of  this  city  for 
coping  with  this  dreaded  scourge  are  totally  inadequate;  and 

Whereas,  The  best  and  most  effective  modern  scientific 
methods  for  treating  consumption  are,  by  reason  of  their  ex- 
pensiveness,  out  of  reach  of  the  poor,  who  are,  nevertheless, 
the  greatest  sufferers  from  the  disease ;  be  it 

Resolved,  That  this  board  is  in  favor  of  the  establishment  by 
the  city  of  New  York,  within  the  shortest  possible  time,  of  a 
hospital  in  the  near  neighborhood  of  the  city  for  the  treatment 
of  consumptives ;  and 

293 


Resolved,  That  the  Commissioner  of  Charities  be,  and  he  is 
hereby,  requested  to  prepare  a  report  on  the  establishment  of 
such  a  hospital,  showing  the  amount  of  ground  necessary,  the 
proper  location,  the  general  type  of  building  required,  and  the 
probable  expense  of  the  land,  building,  and  maintenance,  and 
such  other  details  as  may  be  necessary  to  admit  of  intelligent 
action ;  and 

Resolved,  That  the  Commissioner  of  Charities  be,  and  he 
hereby  is,  requested  to  submit  said  report  to  the  Board  of  Esti- 
mate and  Apportionment  with  a  request  for  an  appropriation 
of  the  amount  of  money  sufficient  to  establish  and  maintain 
such  an  hospital ;  also 

Resolved,  That  the  president  of  the  Board  of  Health  be  re- 
quested to  supply  an  estimate  to  this  board,  showing,  as  near 
as  may  be,  the  total  number  of  persons  in  this  city  now  suffer- 
ing from  consumption,  and  giving  as  careful  an  estimate  as 
may  be  of  the  number  of  new  cases  which  may  be  expected  to 
develop  each  year  for  the  next  five  years,  in  order  that  this 
board  may  have  an  approximate  basis  for  judging  of  what 
hospital  accommodation  it  might  probably  be  necessary  to 
provide,  in  order  to  take  care  in  a  proper  manner  of  all  per- 
sons stricken  with  this  disease ;  and 

Resolved,  That  the  president  of  the  Board  of  Health  be  re- 
quested to  state  to  this  board  whether,  in  case  sufficient  hos- 
pital accommodation  were  provided  to  take  care  of  all  cases  of 
consumption  that  should  develop,  there  would  be  any  scientific 
basis  for  the  belief  that  consumption  as  a  scourge — that  is  to 
say,  as  one  of  the  leading  causes  of  death — could  be  abolished 
in  this  city,  and  if  so  within  what  period  of  time ;  also 

Resolved,  That  if  there  are  certain  simple,  physical  exercises, 
requiring  little  or  no  apparatus,  and  which  are  calculated  to 
ward  off  consumption  from  those  persons  predisposed  to  it, 
the  president  of  the  Board  of  Health  be,  and  he  hereby  is,  re- 
quested to  print  and  distribute  plain  and  practical  and  readily 
intelligible  instructions,  describing  and  illustrating  such  ap- 
proved methods  of  lung  and  chest  development  and  explaining 
their  object  and  probable  results. 

294 


Pursuant  to  the  instructions  therein  contained,  I  beg  to 
submit  the  following  report  on  the  establishment  of  a  municipal 
sanatorium  for  consumptives: 

In  considering  the  question  of  location,  it  seemed  to  me  that 
the  first  step  was  to  ascertain  what  elevation,  if  any,  is  now 
considered  essential  by  the  best  medical  authorities  for  such 
an  institution  as  the  one  proposed.  Until  recently  physicians 
have,  as  a  rule,  held  that  a  very  considerable  elevation  is 
necessary  for  the  treatment  of  this  disease.  Whatever  eleva- 
tion is  considered  essential  will  of  necessity  determine  the 
limits  within  which  the  choice  of  a  particular  location  may  be 
made.  I  therefore  addressed  a  letter  on  May  6th  to  eleven 
eminent  physicians,  all  of  whom  are  connected  either  with  hos- 
pitals for  the  treatment  of  consumption  or  other  movements 
for  the  prevention  of  the  spread  of  this  disease.  All  of  these 
physicians  have  kindly  replied,  many  of  them  stating  in  some 
detail  their  views  on  the  question.  There  seems  to  be  una- 
nimity of  opinion  that  an  out-of-town  site  with  some  elevation 
is  essential.  Seven  of  the  eleven  consider  an  elevation  of 
from  600  to  1000  feet  satisfactory;  two  suggest  1200  to  1500 
as  extremely  desirable ;  and  two  strongly  favor  an  elevation  of 
2000  feet. 

In  addition  to  an  elevation  of  from  600  to  1000  feet,  the 
requirements  in  the  matter  of  location,  as  indicated  by  these 
medical  authorities,  are  a  porous  soil,  opportunity  for  good 
drainage,  sufficient  remoteness  from  cities  and  villages  to  en- 
sure pure  air,  shelter  from  the  north  and  northeast  winds,  an 
abundant  water  supply  of  good  quality,  an  attractive  outlook, 
and  accessibility  to  a  railway  station.  I  have  carefully  ex- 
amined the  topography  of  the  several  counties  reasonably  ac- 
cessible to  New  York  City,  as  shown  by  the  maps  of  the  United 
States  Geological  survey,  and  have  examined  in  person  a  num- 
ber of  sites.  I  am  prepared  to  state  that  there  can  be  found 
within  a  distance  of  fifty  miles  from  New  York  City,  and  prob- 
ably within  forty  miles,  a  considerable  number  of  sites  offering 
an  elevation  of  from  600  to  1000  feet,  and  in  a  reasonable 
degree  the  other  requirements  indicated  above.      This  would 

295 


mean  that  the  friends  and  relatives  of  the  patients  could  visit 
them  without  losing  more  than  a  half  day  from  their  usual  em- 
ployment, and  at  an  expense  not  exceeding  $i.6o  for  railroad 
fare,  or  if  half  rates  could  be  secured,  as  would  probably  be 
the  case,  not  exceeding  eighty  cents.  These  considerations 
will  prove  to  be  important  in  their  influence  upon  the  willing- 
ness of  patients  to  be  sent  to  the  sanatorium. 

To  secure  the  use  of  any  one  of  these  sites,  it  must  be  se- 
lected by  the  Board  of  Health  of  the  city,  and  it  will  then  be 
necessary,  under  existing  legislation,  to  secure  the  consent  of 
the  town  board,  the  county  board  of  supervisors,  the  State 
Board  of  Health,  and  presumably  the  local  Board  of  Health. 
Under  these  circumstances,  it  does  not  seem  advisable  at  this 
time  to  recommend  any  particular  site.  I  suggest  that  a 
competent  expert  be  appointed  to  devote  all  his  time  to  the 
examination  of  sites  and  securing  the  necessary  consents  for 
such  site  as  the  Board  of  Health  may  select,  as  soon  as  the 
Board  of  Estimate  and  Apportionment  takes  favorable  action 
on  the  general  plan. 

The  amount  of  ground  needed  will  depend  on  the  capacity 
of  the  proposed  institution,  and  also  upon  the  character  of  the 
country  immediately  adjacent  to  the  site.  It  should  be  suf- 
ficient to  ensure  the  preservation  of  surrounding  forests  to  the 
north  and  northeast  and  to  prevent  undesirable  neighbors  in 
the  immediate  vicinity  of  the  buildings.  It  should,  if  possible, 
be  sufficient  to  provide  for  walks  for  the  patients,  affording 
diversity  of  outlook  without  climbing  and  without  leaving  the 
property  of  the  institution.  It  should  be  sufficient  to  enable 
the  hospital  to  maintain  a  considerable  dairy  and  to  carry  on 
the  raising  of  poultry  and  also  vegetable  and  fruit  raising. 
These  are  needed  both  for  reasons  of  economy  and  to  provide 
healthful  interesting  occupation  for  such  of  the  patients  as  are 
able  to  engage  therein.  I  should  suggest  that  for  a  hospital 
to  accommodate  500  patients  there  should  be  secured  if  pos- 
sible from  250  to  400  acres  of  land. 

Fortunately,  it  will  not  be  necessary  for  the  city  to  construct 
expensive  buildings  for  this  purpose,  except  for  such  service 

296 


Alternate  Tent  Plan  for  a  Municipal  Sanatorium. 


buildings  as  power  house,  administration  building,  etc.  Cheap 
wooden  structures  for  some  of  the  patients  and  tent  cottages, 
such  as  have  been  constructed  at  the  Tuberculosis  Infirmary 
connected  with  the  Metropolitan  Hospital,  Blackwell's  Island, 
by  this  department,  are  inexpensive  and  are  probably  better 
suited  to  the  needs  of  the  patients,  so  far  as  dormitory  purposes 
are  concerned,  than  more  expensive  buildings.  The  cost  of 
these  tent  cottages  at  Blackwell's  Island,  accommodating 
twelve  patients  each,  is  about  $90  for  materials  and  $30  for 
labor.  I  have  received  from  the  Committee  on  the  Prevention 
of  Tuberculosis,  appointed  by  the  Charity  Organization  Society, 
two  sets  of  plans  and  sketches  for  a  Municipal  Sanatorium  for 
Tuberculosis,  one  prepared  by  Messrs.  Renwick,  Aspinwall, 
&  Owen,  and  the  other  by  Messrs.  Howells  &  Stokes.  Each 
of  these  sets  of  plans  is  accompanied  by  a  letter  from  the  archi- 
tects setting  forth  the  general  plan  and  arrangement  of  the 
buildings,  the  style  of  architecture,  character  of  construction, 
and  the  probable  cost.  I  believe  that  each  of  these  plans  is 
well  adapted  to  the  proposed  purpose,  though  I  believe  that  a 
smaller  number  of  dormitories  of  a  permanent  character  will 
be  needed  at  the  outset,  and  that  a  larger  proportion  of  the 
patients  can  advantageously  be  provided  for  in  tent  cottages 
or  in  temporary  wood  structures.  I  submit  herewith  copies 
of  each  of  the  sketches  and  plans,  and  the  explanatory  letters 
by  the  architects  accompanying  the  same.  These  are  sub- 
mitted merely  as  suggestions  of  the  general  character  of  build- 
ings now  favored  for  such  purposes.  Which  of  the  two  plans 
should  be  selected,  or  whether  an  entirely  new  plan  should  be 
prepared,  or  whether  features  of  both  plans  should  be  favored, 
would  naturally  depend  largely  upon  the  character  and  im- 
mediate surroundings  of  the  site  selected. 

PROBABLE   EXPENSES   FOR   LAND,    BUILDING,   AND 

MAINTENANCE 

So  much  depends  upon  the  immediate  surroundings  of  the 
site  which  may  be  selected,  that  it  is  hardly  possible  to  give 

397 


even  an  approximate  estimate  of  the  cost  of  the  land.  I  should 
presume,  however,  that  such  a  site  as  is  desired  could  hardly 
be  secured  for  less  than  $ioo  per  acre,  and  that,  in  any  case, 
it  should  not  cost  more  than  $250  per  acre,  or  for  a  total  of 
250  acres  from  $25,000  to  $62,500,  or  for  400  acres  from  $40,000 
to  $100,000. 

The  cost  of  buildings  and  plants  as  estimated  by  Messrs. 
Renwick,  Aspinwall,  &  Owen,  according  to  the  plans  submitted 
by  them,  for  accommodations  for  480  patients  is  $530,000;  for 
accommodation  for  325  patients,  $278,000;  for  accommodation 
for  286  patients,  $210,000.  The  estimate  given  by  Messrs, 
Howells  &  Stokes  of  the  cost  of  construction,  not  including 
grading,  building  roads,  etc.,  on  their  plan,  accommodating 
500  patients,  is  $407,000. 

It  is  my  own  opinion  that  unless  the  site  selected  presented 
unusual  diflficulties,  a  satisfactory  sanatorium,  to  accommodate 
500  patients,  can  be  constructed,  complete,  for  the  sum  of 
$450,000. 

Inquiry  of  a  number  of  existing  institutions  for  the  care  of 
consumptives  shows  wide  difference  in  the  cost  of  maintenance. 

The  annual  report  of  the  Massachusetts  State  Sanatorium  at 
Rutland,  Mass.,  shows  (page  16)  that  the  average  cost  of  main- 
tenance per  day  during  the  year  ending  September  30,  1902, 
was  $1.42.  This  institution  is  devoted  solely  to  the  treatment 
of  patients  in  the  early  stages  of  the  disease,  every  effort  being 
made  to  avoid  the  admission  of  patients  who  have  passed  the 
helpful  stage.  The  average  number  of  patients  during  the 
year  was  177.  The  per-capita  expenditure  would,  no  doubt, 
have  been  considerably  less  with  an  average  of  500  patients,  as 
supplies  could  be  bought  more  advantageously  in  larger  quan- 
tities. This  institution  endeavors  to  provide  the  best  possible 
diet  for  the  patients  under  treatment. 

The  per-capita  cost  of  maintenance  at  the  Bedford  Sana- 
torium for  Consumptives  in  Westchester  County,  a  branch  of 
the  Montefiore  Home,  with  an  average  census  of  134  patients, 
was  seventy-six  and  eight-tenths  cents  per  diem  for  the  year 
ending  September  30,  1902.     This  institution  received  about 

398 


fifty-eight  per  cent  of  advanced  cases.  During  the  three  pre- 
ceding years  the  per-capita  cost  varied  from  seventy-eight  to 
eighty-one  cents  per  day.  The  raising  of  produce  on  the  farm 
assists  in  reducing  the  per-capita  cost. 

The  Loomis  Sanatorium  at  Liberty,  Sullivan  County,  re- 
ports the  per-capita  cost  of  maintenance  at  the  sanatorium 
annex,  which  is  on  the  ward  plan,  as  about  $1.21  per  diem. 
This  is  based  on  the  care  of  about  thirty  patients  in  the  early 
stages  of  the  disease.  A  larger  number  would  reduce  the  per- 
capita  cost. 

The  St.  Joseph's  Hospital  for  Consumptives,  which  cared 
for  an  average  of  345  advanced  cases  during  1902,  reports  the 
per-capita  cost  per  diem  as  eighty  cents. 

At  Seton  Hospital,  with  an  average  of  195  patients  during 
1902,  the  per-capita  cost  of  maintenance  was  seventy-nine  and 
three-tenths  cents.  This  institution  receives  both  incipient 
and  advanced  cases. 

At  the  Metropolitan  Hospital  on  Blackwell's  Island  the  per- 
capita  cost  in  1902  for  all  patients,  averaging  623  in  number, 
tuberculous  and  otherwise,  was  seventy-four  cents  per  diem. 
While  the  cost  of  the  diet  of  the  tuberculous  patients  at  that 
institution  is  six  and  one-half  cents  per  diem  more  than  that 
of  the  other  patients,  the  cost  of  nursing  and  of  medical  and 
surgical  supplies  is  much  less,  so  that  the  per-capita  per-diem 
cost  of  the  tuberculous  patients  at  this  institution  is  not  far 
from  seventy  cents  per  diem.  The  actual  per-capita  cost  of 
the  tuberculous  patients  during  May,  1903,  was  sixty-one 
cents  per  diem.  This  does  not  include  light,  and  the  cost  for 
fuel  was  much  less  than  the  average  cost  of  that  item  for  the 
year.  The  majority  of  the  patients  are  in  a  more  or  less  ad- 
vanced stage  of  the  disease,  but  all  are  provided  with  such 
treatment  as  is  considered  by  the  medical  authorities  of  the 
institution  as  best  adapted  for  their  improvement. 

In  view  of  the  fact  that  the  proposed  sanatorium  is  to  be  for 
the  treatment  of  cases  in  the  early  stages  of  the  disease  and 
as  plenty  of  food,  especially  eggs  and  milk,  is  a  necessary 
feature  of  the  treatment,  I  should  estimate  the  cost  per  capita 

299 


per  diem  at  $i.oo,  or  a  total  for  the  year,  for  an  average  of  500 
patients,  of  $182,500.  This  amount  might  be  reduced  if  suf- 
ficient land  were  provided  to  permit  the  carrying  on  of  dairying, 
poultry  raising,  and  vegetable  and  fruit  raising  on  a  consider- 
able scale.  In  this  estimate  I  have  taken  the  term  maintenance 
as  including  the  cost  of  food,  clothing,  bedding,  salaries, 
medical  supplies,  light  and  fuel,  and  ordinary  repairs. 

At  the  present  time  fully  one-third  of  all  consumptives  now 
under  care,  in  or  near  the  city  of  New  York,  including  the 
Sanatorium  in  Sullivan  County  and  in  the  Adirondacks,  are 
under  the  care  of  the  Department  of  Public  Charities  at  the 
Tuberculosis  Infirmary  on  Blackwell's  Island  and  at  the  King's 
County  Hospital.  The  number  of  tuberculous  patients  in 
these  institutions  on  July  i,  1903,  was  as  follows: 

Tuberculosis  Infirmary,  Blackwell's  Island 391 

Kings  County  Hospital,  Brooklyn 60 

Total 451 

The  Tuberculosis  Infirmary  on  Blackwell's  Island  was  opened 
on  January  31,  1902,  and  received  within  a  few  months  after 
its  establishment  all  consumptive  patients  from  the  hospitals 
and  institutions  in  the  Department  of  Public  Charities,  and, 
with  the  exception  of  the  patients  in  two  small  wards,  all  those 
in  the  hospitals  under  the  direction  of  Bellevue  and  Allied 
Hospitals.  Every  effort  was  made  to  administer  the  institu- 
tion on  progressive  lines  and  to  afford  such  food,  clothing, 
treatment,  and  care  as  would  tend  to  the  improvement  of  all 
patients  whose  condition  permitted  of  improvement.  The  in- 
firmary steadily  increased  in  numbers  until  the  capacity  of  the 
buildings  was  taxed  to  the  utmost ;  to  relieve  this  pressure  and 
also  to  afford  a  larger  measure  of  out-of-door  life,  seven  tent 
cottages  have  been  constructed  during  the  past  two  months 
which  provide  at  present  for  thirty  patients.  The  construction 
of  tent  cottages  is  being  continued,  and  by  August  15th,  it 
is  expected  that  fully  1 50  patients  will  be  thus  provided  for. 

While  the  establishment  of  the  Tuberculosis  Infirmary  on 

300 


Blackwell's  Island  is  producing  many  important  and  highly 
satisfactory  results,  in  securing  the  segregation  of  consump- 
tives from  other  patients  in  the  municipal  hospitals,  in  the  re- 
moval of  a  larger  proportion  of  both  early  and  advanced  cases 
from  the  tenement-house  districts,  and  in  showing  marked 
improvement  on  the  part  of  many  of  the  patients  received  at 
this  institution,  it  has  already  demonstrated  the  fact  that  it  is 
practically  impossible,  as  it  is  also  undesirable,  to  provide  on 
Blackwell's  Island  for  anything  like  the  number  who  will  cer- 
tainly apply  for  admission  and  who  should  be  received.  Our 
experience  indicates  that  there  should  be  established,  as  is 
contemplated  by  the  resolution  adopted  by  the  Board  of 
Aldermen  and  approved  by  his  Honor,  the  Mayor,  another 
institution  in  the  country,  at  a  greater  altitude,  with  a  much 
larger  site,  and  with  opportunity  for  daily  light  employment, 
to  which  patients  most  likely  to  profit  by  such  surroundings 
can  be  sent.  This  new  institution  should  sustain  such  relation 
to  the  Tuberculosis  Infirmary  as  will  facilitate  the  freest  inter- 
change of  patients,  according  to  their  condition  from  time  to 
time. 

The  work  of  the  proposed  sanatorium  is,  perhaps,  more 
nearly  akin  to  that  of  the  board  of  trustees  of  Bellevue  and 
Allied  Hospitals  than  that  of  any  other  existing  board  or  de- 
partment. The  fact  that  the  Commissioner  of  Charities  is 
ex  officio  a  member  of  that  board  would  ensure  co-operation 
between  the  new  institution  and  the  work  now  or  hereafter 
carried  on  by  the  Charities  Department.  The  Department  of 
Health,  to  which  cases  of  this  disease  are  reported  in  the  first 
instance,  could  refer  such  cases  as  its  investigators  indicate 
should  receive  sanatorium  treatment  to  the  trustees. 

I  therefore  respectfully  recommend  : 

(i)  That  the  Board  of  Estimate  and  Apportionment  express 
its  approval  of  the  establishment  of  a  municipal  sanatorium  for 
consumptives  of  the  general  character  of  that  herein  described. 

(2)  That  the  Board  of  Estimate  and  Apportionment  request 
the  Board  of  Health  to  select  a  site  for  such  sanatorium  at 
the  earliest  practicable  moment,  and  in  co-operation  with  the 

301 


board  of  trustees  of  Bellevue  and  Allied  Hospitals  secure  the 
necessary  consents  therefor. 

(3)  That  the  Board  of  Estimate  and  Apportionment  request 
the  board  of  trustees  of  Bellevue  and  Allied  Hospitals  to  co- 
operate with  the  Board  of  Health  in  selecting  such  site  and  in 
securing  the  necessary  consents  therefor,  and  to  establish  and 
maintain  thereon,  when  the  use  of  such  site  has  been  secured, 
a  sanatorium  for  consumptives. 

(4)  That  an  appropriation  of  the  sum  of  $30,000  be  made, 
through  the  issue  of  special  revenue  bonds,  to  the  board  of 
trustees  of  Bellevue  and  Allied  Hospitals  to  cover  the  cost 
of  selection  of  site  and  maintenance  during  the  remainder  of 
the  current  year. 

(5)  That  an  issue  of  bonds  to  the  amount  of  $400,000  be 
authorized  for  the  construction  by  the  board  of  trustees  of 
Bellevue  and  Allied  Hospitals  of  a  municipal  sanatorium  for 
consumptives. 

All  of  which  is  respectfully  submitted. 

Homer  Folks, 
Commissioner  of  Public  Charities. 

July  15,  1903. 


303 


Appendix  i6 
THE  PLAGUE  IN  ITS  STRONGHOLD 

TUBERCULOSIS  IN  THE   NEW 
YORK  TENEMENT 

By  ERNEST  POOLE 

"  We  must  care  for  the  consumptive  in  the  right  place,  in  the  right  way,  and  at 
the  right  time,  until  he  is  cured  ;  instead  of,  as  now,  in  the  wrong  place,  in  the 
wrong  way,  at  the  wrong  time,  until  he  is  dead." — J.  H.  Pryor. 


303 


S       lo   .S^ 


,c 

? 

s;^ 

^ 

S 

i. 

4> 

j: 

■a 

K 

H  u 


li3U±9      3NIH3HJ.V0 


THE    PLAGUE    IN   ITS   STRONGHOLD 

THE  PRAYER  OF  THE  TENEMENT 

"Breath — breath — give  me  breath !  "  A  Yiddish  whisper, 
on  a  night  in  April,  1903,  from  the  heart  of  the  New  York 
Ghetto. 

At  18  Clinton  Street,  back  in  the  rear  tenement,  a  young 
Roumanian  Jew  lay  dying  of  consumption,  I  had  come  in 
with  a  Jewish  doctor.  With  every  breath  I  felt  the  heavy, 
foul  odor  from  poverty,  ignorance,  filth,  disease.  In  this  room 
ten  feet  square  six  people  lay  on  the  floor  packed  close,  rub- 
bing the  heavy  sleep  from  tired  eyes  and  staring  at  us  dumbly. 
Two  small  windows  gave  them  air,  from  a  noisome  court — a 
pit  twenty  feet  across  and  five  floors  deep.  The  other  room 
was  only  a  closet  six  feet  by  seven,  with  a  grated  window  high 
up  opening  on  an  air-shaft  eighteen  inches  wide.  And  in  that 
closet  four  more  were  sleeping,  three  on  a  bed,  one  in  a  cradle. 

"Breath — breath — give  me  breath  !  "  The  man's  disease  was 
infectious ;  and  yet  for  two  long  weeks  he  had  lain  here  dying. 
From  his  soiled  bed  he  could  touch  the  one  table,  where  the 
two  families  ate ;  the  cooking  stove  was  but  six  feet  from  him  ; 
the  cupboard,  over  his  pillow ;  he  could  even  reach  one  of  the 
cradles,  where  his  baby  girl  lay  staring  frightened  at  his  strange 
position :  for  his  wasted  body  was  too  feeble  to  rise ;  too 
choked,  too  tortured,  to  lie  down.  His  young  wife  held  him 
up  while  the  sleepers  stared  silently  on,  and  that  Yiddish 
whisper  came  over  and  over  again,  but  now  with  a  new  and 

305 


more  fearful  meaning:  "Breath — breath — breath!  Or  kill 
me ;  oh,  kill  me  !  ' ' 

Two  years  ago  this  man  had  come  to  America — one  of  the 
four  hundred  and  eighty-eight  thousand  in  1901.  He  came 
young  and  well  and  hopeful,  with  his  wife  and  their  baby  son. 
Two  more  had  been  born  since  then.  It  was  to  be  a  new 
country,  a  new  home,  a  fresh  start,  a  land  to  breathe  in. 
"Breath — breath — give  me  breath  !  "  He  had  breathed  no  air 
here  but  the  close,  heavy  air  of  the  sweat-shop,  from  six  in  the 
morning  until  ten  at  night.  Sometimes — he  whispered — he 
worked  on  until  eleven.  He  was  not  alone.  In  New  York 
to-day  and  to-night  are  over  fifty  thousand  like  him  working. 
And  late  in  the  night  when  he  left  the  feverish  labor,  at  the 
hour  when  other  homes  are  sleeping,  he  had  come  in  through 
the  foul  court  and  had  sunk  into  restless  sleep  in  the  dark 
closet  six  feet  by  seven.  There  are  three  hundred  and  sixty-one 
thousand  such  closets  in  the  city.     And  this  was  his  "home." 

"Luft — giebt  mir  luft !  "  He  spoke  only  Yiddish.  The  new 
country  had  given  the  Plague  before  the  language.  For  the 
sweat-shop  and  the  closet  had  made  him  weak;  his  weakened 
body  could  make  no  fight;  the  Plague  came  in  and  fed  swiftly. 
Still  on  through  the  winter  he  had  worked  over  the  machine  in 
the  sweat-shop,  infecting  the  garments  he  sewed — feverish, 
tired,  fearful — to  buy  food  and  coal,  to  keep  his  "home  "  alive. 
And  now,  on  this  last  day  of  life,  ten  times  he  had  whispered 
to  his  brother,  begging  him  to  care  for  the  wife  and  the  three 
little  children.  • 

The  struggle  now  is  ended.  The  home  is  scattered.  The 
smothered  whisper  is  forever  hushed.  "Breath — breath^ — give 
me  breath  !  "     It  speaks  the  appeal  of  thousands. 

THE  GREATEST  OF  PLAGUES :    AN  UNNECESSARY  EVIL 

This  Plague  Consumption  is  to  be  stamped  out  once  for  all. 
It  has  hung  upon  the  earth  for  thousands  of  years.  It  has 
killed  not  millions  but  billions  of  men,  women,  and  children; 
more  than  all  wars  and  plagues  the  world  over.     And  now  of 

306 


the  seventy  millions  in  our  country,  seven  millions  must  in- 
evitably die  of  this  scourge  unless  the  present  ratio  be  brought 
down.  Each  year  it  kills  over  a  hundred  thousand  of  our  men 
and  women,  and  most  of  these  are  cut  off  in  the  very  prime  of 
life.  To  women  between  twenty  and  forty-five  it  brings  one- 
third  of  all  deaths;  to  men  between  thirty  and  forty-five  it 
brings  thirty-two  per  cent.  Most  startling  of  all — to  young 
men  between  twenty  and  twenty-nine  it  brings  no  less  than 
thirty-six  per  cent,  of  deaths  from  all  causes.  It  is  a  Plague  in 
disguise.  Its  ravages  are  insidious,  slow.  They  have  never 
yet  roused  a  people  to  great,  sweeping  action.  The  Black 
Plague  in  London  is  ever  remembered  with  horror.  It  lived 
one  year;  it  killed  fifty  thousand.  The  Plague  Consumption 
kills  this  year  in  Europe  over  a  million ;  and  this  has  been 
going  on  not  for  one  year  but  for  centuries.  It  is  the  Plague 
of  all  plagues — both  in  age  and  in  power, — insidious,  steady, 
unceasing. 

It  can  be  stamped  out.  Its  workings  are  no  longer  hidden. 
We  know  now  that  consumption  is  not  produced  by  direct 
heredity — the  tendency  alone  is  inherited.  It  is  produced  by 
infection  from  living  germs,  coughed  up,  millions  in  a  day. 
Ignorance  lets  these  millions  live,  spat  out  on  walls  and  floors 
and  pavements,  to  float  later  in  the  air  and  so  spread  the  in- 
fection. Darkness,  foul  air,  and  filth  keep  these  millions  alive. 
Sunlight  has  killed  them  in  fifteen  minutes;  in  dark  tenement 
halls  they  are  known  to  have  lived  two  years.  Darkness,  foul 
air,  ignorance,  drink — these  weaken  men,  women,  and  children, 
and  so  make  them  ready  for  infection.  Then  the  germs,  if 
breathed  in,  may  bring  pulmonary  tuberculosis  —  consump- 
tion; or  if  swallowed,  tuberculosis  of  the  stomach  or  the  intes- 
tines; or  if  brought  in  contact  with  a  wound,  tuberculosis  of 
the  skin  or  of  the  joints.  These  latter  forms  are  most  common 
in  little  children.  They  bring  but  one-fourth  of  all  deaths  from 
the  Plague.  Tuberculosis  of  the  lungs  is  the  one  great  form  of 
the  Plague  to  be  fought  above  all  others.  It  can  be  stamped 
out. 

In  New  York  City  a  strong  beginning  has  already  been  made- 

307 


While  the  population  has  vastly  increased  in  the  last  twenty 
years,  the  number  of  deaths  from  this  cause  has  remained 
about  the  same.  Far  greater  effort,  however,  is  now  called 
for.  Dr.  Hermann  M.  Biggs,  Medical  Ofificer  of  the  Depart- 
ment of  Health,  has  recently  said:  "The  measures  now  in 
force  are  quite  inadequate  as  compared  to  the  importance  and 
magnitude  of  the  problem.  The  sanitary  authorities,  however 
enthusiastic  and  efificient,  and  the  medical  profession,  however 
influential  and  numerous,  cannot  grapple  with  this  problem 
unless  they  have  the  hearty  support  of  the  people."  And  he 
adds:  "I  believe  that  tuberculosis  may  be  practically  stamped 
out."  This  is  said  from  years  of  wide  experience.  It  is  sup- 
ported by  science  the  world  over.  Experience  everywhere  has 
shown  just  what  must  be  done.  The  time  is  ripe  for  the  peo- 
ple to  act  on  a  tremendous  scale.  Not  hundreds,  not  thou- 
sands, but  tens  of  thousands  are  to  be  saved  for  New  York 
City  alone  in  these  next  ten  years.  They  are  to  be  saved  by 
attacking  this  Plague  in  its  stronghold. 

THE  STRONGHOLD  OF  THE  PLAGUE 

Its  stronghold  is  the  tenement.  Statistics  prove  this  the 
world  over.  They  show  in  New  York  State  that  in  cities  of 
over  twenty-five  thousand — now  swiftly  absorbing  young  men 
from  the  country,  so  making  the  problem  still  more  appalling 
— the  death-rate  from  consumption  is  over  twice  the  rate  in 
smaller  towns  and  villages.  In  the  city  it  is  worst  of  all  in  the 
tenements.  In  New  York  City  to-day  there  are  at  least  twenty 
thousand  in  the  tenements  who  are  suffering  in  some  stage  of 
this  disease.  It  is  here  among  the  crowded  poor  that  the 
Plague  feeds  fat  on  ignorance  and  poverty,  in  dark  halls,  foul 
rooms,  dark  closets.  It  is  here  that  it  shatters  the  home  as 
it  has  shattered  homes  among  us  all.  Here  it  fastens  on  the 
bread-winner,  eating  up  the  small  savings,  lingering  on  for 
months  and  even  years,  so  making  the  greatest  of  human 
powers — Love — only  a  means  of  infection  and  death.  It  is 
from  here  that  sweat-shop  garments  and  wares  of  all  kinds  go 

308 


out  infected  to  all  classes  of  people.      It  is  here  that  unceasing 
danger  lies  for  the  whole  community. 

"the  lung  block  " 

"The  Lung  Block  "  has  well  earned  its  name.  It  is  bounded 
by  the  streets  Cherry,  Catharine,  Hamilton,  Market.  It  is 
close  to  the  East  River — to  open  air.  It  should  be  wholesome. 
For  a  month  I  worked  through  it  with  the  help  of  those  who 
know  it  best.  I  went  through  with  health  and  tenement  in- 
spectors, as  a  settlement  visitor  one  week,  as  a  "fresh-air 
man  "  the  next.  I  use  this  one  block  as  a  centre,  not  to 
prove,  but  to  image  what  has  already  been  proved  all  through 
the  civilized  world,  to  image  the  three  great  evils  we  must 
fight  in  the  tenement.  These  evils  are  Congestion,  Dissipa- 
tion, Infection. 

That  the  Plague  spreads  with  congestion  has  long  been 
proved  beyond  the  shadow  of  a  doubt.  It  spreads  even  faster 
than  the  crowd  pours  in.  So  it  is  in  the  block  we  have  taken. 
It  stands  in  one  of  the  most  congested  wards  of  the  most 
crowded  city  in  the  world,  and  this  Seventh  Ward  is  steadily, 
swiftly  packing  closer.  Between  1890  and  1900,  the  density 
of  its  already  crowded  population  increased  no  less  than  sixty- 
five  per  cent.  Now  it  holds  four  hundred  and  seventy-eight 
humans  to  an  acre.  The  Lung  Block  alone  holds  nearly  four 
thousand,  not  to  mention  dogs,  cats,  parrots  and  one  weakened 
old  monkey.      Of  the  humans,  some  four  hundred  are  babies. 

It  is  a  block  packed  close  with  huge  grimy  tenements  ;  these 
tenements  are  honeycombed  with  rooms ;  these  rooms  are 
homes  for  people.  To  squeeze  in  more  homes,  light  and  air 
are  slowly  shut  out.  Halls,  courts,  air-shafts,  are  all  left 
cramped  and  deep  and  sunless. 

It  is  a  block  of  a  thousand  homes.  Through  halls,  in  rooms, 
on  stairways,  in  courts,  in  shafts,  and  out  on  fire-escapes,  are 
sprinkled  the  four  hundred  babies.  At  the  age  of  two  they 
are  found  alone  in  the  street,  already  imbibing  its  deep,  muddy 
wisdom.     So  this  muddy  street  overflows  into  the  home.     It 

309 


is  hard  for  the  home  to  keep  wholesome  and  pure.  Things 
and  people — good  and  bad — have  only  partitions  between 
them. 

In  a  block  so  congested  the  Plague  spreads  swiftly.  In  the 
past  nine  years  alone,  this  block  has  reported  two  hundred 
and  sixty-five  cases.  From  doctors,  druggists,  and  all  others 
who  know,  I  gathered  that  this  is  but  half  the  true  number. 

In  a  block  so  congested  dissipation  comes  easy.  Foul  air, 
darkness,  wretched  surroundings — these  work  on  the  home  by 
day  and  by  night.  Here  a  thousand  homes  struggle  on,  while 
hundreds  yield  and  sink  and  so  pollute  the  others.  So  come 
squalid  homes  and  wretched  meals.  So  comes  the  humorous, 
shattered  old  chap  who  told  me,  "I  aint  never  sober  but  when 
I  gits  out  of  bed."  So  come  hundreds  of  others,  men  and 
women,  young  and  old ;  drunk,  bestial,  vile,  forever  steadily 
sinking.  "Hard  drinking  triples  susceptibility  to  consump- 
tion." This  is  seen  most  of  all  in  the  Irish;  hence  among  the 
Irish  the  death-rate  from  the  Plague  is  twice  that  of  any  other 
white  nationality.  The  Jews,  with  their  strict  habits,  their 
dietary  laws,  and  a  certain  standard  of  cleanliness  enforced  by 
a  rigid  religion,  show  the  lowest  death-rate  of  all,  though  this 
is  rising  as  they  become  tenementized.  At  present,  the  Lung 
Block  has  only  Jews  on  the  Market  Street  end,  and  among 
them  we  found  hardly  a  case  of  consumption.  The  body  of 
the  block  is  packed  with  Irish  and  Italians,  and  a  sprinkling  of 
twelve  other  peoples.  All  these  image  best  the  dissipation, 
the  shattered  vitality  which  eats  into  savings,  starves  the 
home,  then  gives  the  Plague  easy  entrance,  and  makes  it  a 
constant  danger  to  all  in  the  family. 

I  give  here  but  a  few  brief  tales  among  many.  In  a  tene- 
ment old,  vile,  infected,  one  of  the  worst  on  the  block,  an 
Italian  lived  some  two  years  back.  He  had  a  wife  and  three 
little  children.  They  lived  in  one  room  and  a  closet.  They 
lived  on  four  dollars  a  week.  To  make  a  home  wholesome 
here  means  unceasing  struggle.  His  wife  gave  up  and  took  to 
drink.  The  man  struggled  on.  He  worked  hard  to  support 
his  babies,  but  it  was  a  wretched  home  to  come  to  at  night. 

310 


Even  the  neighbors  said  so.  The  house  was  infected,  and 
against  its  infection  the  home  gave  no  protection,  but  only- 
wretched  food,  wretchedly  cooked,  for  the  tired  man  and  his 
little  children.  The  man  took  the  Plague.  He  worked  on. 
Friends  tried  to  make  him  stop.  "No:  Me  die  not  yet  at 
all!  Me  gotta  bringa  de  grub  to  ma  chil'."  This  feeling  is  as 
old  as  the  hills.  He  struggled  on.  One -afternoon  he  had  a 
hemorrhage  at  work,  and  was  brought  home  on  a  shutter. 
The  "home"  broke  up.  I  could  find  but  one  more  item. 
The  baby  girl  died  last  year  of  the  Plague — tubercular  menin- 
gitis— over  on  Randall's  Island. 

Not  far  off  lives  a  German  family,  a  mother  and  five  girls, 
the  oldest  sixteen,  the  youngest  four.  The  father  drank,  took 
the  Plague,  and  died.  The  mother  took  it  from  him.  Of  the 
hundred  and  thirteen  dollars  life  insurance,  she  spent  ninety 
dollars  on  his  funeral.  Then  the  starving  began.  The  girl  of 
sixteen  lived  three  months  on  bread  and  tea  alone,  working 
each  day  at  four  dollars  a  week  in  a  factory,  pushing  a  heavy 
treadle  from  six  in  the  morning  until  seven  at  night.  She  had 
worked  so  since  she  was  twelve.  "She  aint  never  seen  the 
country,"  said  her  little  sister,  who  loved  her.  She  went  to 
night  school  always.  She  said  she  "meant  to  be  somebody." 
She  took  the  Plague  in  the  winter,  when  coal  had  gone  up, 
when  the  sleepless  nights  grew  freezing  cold.  It  was  a  brave 
fight,  but  it  is  over.  I  had  her  examined.  She  is  hopeless. 
She  knows  now  what  the  cough  means  when  it  shakes  her 
thin,  hollow  chest ;  and  her  eyes,  when  the  others  are  not 
looking,  have  that  pitiful,  hunted  look' which  young  eyes  must 
ever  have  when  suddenly  meeting  death.  She  had  "meant  to 
be  somebody  "  ;  but  her  father  drank. 

Other  vice  is  thick  in  the  neighborhood.  Among  its  victims, 
with  no  health,  no  love,  no  aid  behind  them,  the  Plague  makes 
fearful  havoc.  ' '  Not  worth  the  bother, "  "  I  know  a  dozen  but 
they  aint  worth  helping  " — so  I  was  told  again  and  again  when 
seeking  for  patients  whom  country  air  might  cure.  Near  by, 
on  South  Street,  stands  a  house  of  ill-fame  with  a  tiny  attic 
overhead,  reached  by  a  ladder.     In  this  place  a  consumptive, 

311 


a  woman,  lay  three  months  cursing  life  and  waiting  for  death. 
Just  before  the  end,  she  was  brought  down  the  ladder  one 
night  like  a  spectre  into  the  brothel,  and  so  out  into  the  ambu- 
lance. Thousands  like  her  have  been  sick  of  this  Plague  in 
New  York.     How  many  have  infected  their  patrons? 

In  one  terrible  house  on  the  block  lived  a  woman  of  ill-fame 
who  had  the  Plague  and  struggled  on — as  a  midwife — for  a 
year. 

But  in  this  block  the  good  outnumber  the  bad  eight  to  one. 
In  my  month  of  work  I  met  some  of  the  kindliest  good  people 
that  ever  lived.  Hundreds  of  homes  are  doing  their  best ;  and 
yet  even  these  homes  cannot  be  wholesome.  The  innocent 
suffer.     I  will  give  only  one  brief  tale. 

It  is  a  story  of  love — Irish  love.  They  had  been  lovers  for 
forty  years,  ever  since  the  wedding  back  in  the  sixties.  Even 
now  their  tender  devotion  was  the  talk  of  the  block.  They 
were  poor  and  had  one  room  with  a  closet  in  a  house  called 
"The  Bucket."  In  this  house  of  homes  the  saloon  below  has 
for  convenience  a  side  door  opening  into  the  hall.  In  nine 
years  the  house  has  reported  fourteen  cases  of  the  Plague. 
The  real  number  must  be  over  twenty.  Foul  air,  darkness, 
ignorance,  drink — all  are  common  here.  But  our  old  couple 
drank  not  a  drop,  and  their  rooms,  I  am  told,  were  neat  as 
wax — useless  cleanliness,  when  halls  and  stairways  are  all  foul, 
infected,  and  black  as  night.  The  old  wife  took  the  Plague. 
For  one  long  year  she  lay  growing  steadily  weaker.  By  day 
the  young  people  came  often  to  sing  and  sew  in  the  room  with 
their  cheery  old  friend.  By  night,  her  husband,  a  watchman 
on  the  dock,  was  away  from  six  until  seven  the  next  morning. 
He  was  sixty-five  and  could  get  no  other  work.  When  friends 
spoke  of  the  hospital,  both  the  old  people  broke  down  com- 
pletely. It  was  never  mentioned  again.  She  kept  so  cheerful 
always  that  he  began  hoping  she  might  get  well.  He  even 
thought  so  one  cold  night  just  after  Christmas,  as  he  ate  his 
supper  while  she  lay  in  the  closet  behind.  She  kissed  him 
good-night  and  was  left  alone.  In  the  morning  at  seven  he 
came  back.     Then  the  woman  next  door  heard  a  low,  shaking 

312 


A  "Lung  Block"  Resident, 


A  "Little  Mother"  and  her  Baby  in  a  Corner  of  their  Only 
Playground. 


cry.     She  found  the  old  man  sobbing  by  the  bedside.     For  his 
wife  was  dead. 

So  the  sober  and  the  drunken,  the  pure  and  the  foul,  the 
well  and  the  sick,  are  all  packed  close  and  mingle.  So  lungs 
are  made  ready  for  the  Plague. 

So,  too,  death  overflows  in  the  tenements.  We  have  seen 
how  congestion  helps  to  bring  drink.  We  have  seen  how  both 
together  make  blood  grow  thin  and  lungs  grow  weak.  To  the 
lungs  so  weakened,  congestion  now  brings  constant  exposure. 
By  the  most  careful  scientific  proof  we  know  that  the  Plague 
can  lodge  for  years  in  tenements.  When  these  infected  tene- 
ments are  crowded  and  dark  and  filthy ;  when  winter  keeps 
thousands  packed  close  inside ;  then  they  can  make  appalling 
records  of  suffering  and  death.  'Of  the  two  hundred  and  sixty- 
five  cases  reported  on  the  block,  one  hundred  and  four  came 
from  the  six  old  tenements  alone. 

There  is  one  called  "The  Ink  Pot."  It  has  front  and  rear 
tenements  five  floors  high,  with  a  foul  narrow  court  between. 
Here  live  one  hundred  and  forty  people.  Twenty-three  are 
babies.  Here  I  found  one  man  sick  with  the  Plague  in  the*front 
house,  two  more  in  the  rear — and  one  of  these  had  a  young 
wife  and  four  children.  Here  the  Plague  lives  in  darkness  and 
filth — filth  in  halls,  over  walls  and  floors,  in  sinks  and  closets. 
Here  in  nine  years  alone  twenty-six  cases  have  been  reported. 
How  many  besides  these  were  kept  secret?  And  behind  these 
nine  years — how  many  cases  more? 

Rooms  here  have  held  death  ready  and  waiting  for  years. 
Up  on  the  third  floor,  looking  down  into  the  court,  is  a 
room  with  two  little  closets  behind  it.  In  one  of  these 
a  blind  Scotchman  slept  and  took  the  Plague  in  '94.  His 
wife  and  his  fifteen-year-old  son  both  drank,  and  the  home 
grew  squalid  as  the  tenement  itself.  He  died  in  the  hospital. 
Only  a  few  months  later  the  Plague  fastened  again.  Slowly 
his  little  daughter  grew  used  to  the  fever,  the  coughing,  the 
long,  sleepless  nights.  The  foul  court  was  her  only  outlook. 
At  last  she,  too,  died.  The  mother  and  son  then  moved  away. 
But  in  this  room  the  germs  lived  on.     They  might  all  have 

313 


been  killed  in  a  day  by  sunlight :  they  can  live  two  years  in 
darkness.  Here  in  darkness  they  lived,  on  grimy  walls,  in 
dusty  nooks,  on  dirty  floors.  Then  one  year  later,  in  October, 
a  Jew  rented  this  same  room.  He  was  taken  and  died  in  the 
summer.  The  room  was  rented  again  in  the  autumn  by  a 
German  and  his  wife.  She  had  the  Plague  already,  and  died. 
Then  an  Irish  family  came  in.  The  father  was  a  hard,  steady 
worker,  and  loved  his  children.  The  home  this  time  was  win- 
ning the  fight.  But  six  months  later  he  took  the  Plague.  He 
died  in  1901,  This  is  only  the  record  of  one  room  in  seven 
years.  In  the  rear  house  is  another  Plague  room — on  the 
ground  floor  to  the  right  of  the  low,  narrow  entrance.  Here, 
in  '96,  lived  an  old  Irish  hat-maker,  with  his  wife,  his  small 
daughter,  his  two  sons.  He  was  housekeeper.  He  took  the 
Plague,  worked  a  year  or  more  there  on  his  hats,  then  died.  The 
cough  came  on  his  wife  soon  after.  She  suffered  long,  weary 
months,  only  to  see  at  the  end  her  young  daughter  begin  the 
same  suffering.  The  mother  died.  The  home  was  shattered. 
The  girl  was  taken  away  by  her  aunt,  and  soon  followed  her 
mother.  The  two  sons  died  of  the  same  disease,  spreading  it 
out  into  other  tenements.  So  by  this  room  one  whole  family 
was  blotted  out.  This  is  not  all.  When  the  next  housekeeper 
came  to  this  same  room  with  his  wife  both  were  strong  and 
well.  The  man  took  the  Plague  in  '99.  He  still  fought  for  life 
when  all  knew  he  was  hopeless  ;  he  still  lived  on  when  he  could 
not  rise,  could  barely  speak,  but  only  lie  alone  in  one  of  these 
closet  bedrooms.  There  are  no  fewer  than  twenty  such  rooms 
in  this  rear  house — windowless,  six  feet  by  eight.  That  winter 
of  1900  brought  the  memorable  blizzard.  While  it  was  raging, 
a  settlement  visitor  came  to  this  room,  and  found  the  water- 
pipe  burst,  the  room  flooded.  The  plucky  little  wife  had  car- 
ried her  husband  upstairs  on  her  back.  A  few  days  later  his 
struggle  was  ended.     The  wife  is  still  here. 

Infection  comes  not  only  from  the  room,  but  as  well  from 
halls  and  stairways.  An  old  Italian,  a  hopeless  victim,  sits  out 
on  the  steps  in  front,  all  day  long  in  the  sun  while  the  children 
play  around  him,  and  all  through  the  evening  with  men  and 

314 


women  beside  him.  His  cough  never  stops.  The  halls  behind 
and  above  are  grimy,  offensive,  hung  heavy  with  cobwebs,  and 
these  cobwebs  are  always  black.  The  stairways  in  the  rear 
house  are  low  and  narrow,  uneven,  and  thick  with  dust  piled 
up  in  every  nook  and  corner.  This  dust  is  virulent  with  dis- 
ease. Through  the  years  a  score  of  consumptives  have  lived 
here,  groping  their  way  each  night  up  the  stairways,  stopping 
on  the  landings  to  catch  their  breath  and  cough,  and  so  spread 
the"  infection.  But  for  light  trickling  through  grimy  panels  in 
doors,  these  halls  are  forever  dark.  It  is  in  halls  like  these 
that  the  germs  can  live  two  years  or  longer.  It  is  with 
halls  like  those  outside  that  one  clean  room  cannot  bring 
safety. 

This  house  is  a  danger  not  only  to  those  who  live  in  it. 
From  here  the  Plague  is  constantly  spreading  out  all  over  the 
city — to  rich  and  poor  alike.  To  show  this  danger,  I  give  the 
few  tales  recorded  here  from  the  many  in  the  past. 

In  this  rear  house  lived  once  an  Italian  family.  They,  too, 
had  little  children,  and  so  were  ambitious,  and  gained  a  name 
with  employers  for  always  doing  good  work.  Their  work  was 
sewing  men's  garments  to  be  sold  later  in  large  clothing  stores. 
The  work  was  all  done  in  their  rooms.  By  working  fourteen 
hours  they  could  make  sixty  cents  each.  In  early  winter  the 
man  gave  out.  His  weakened  body  could  resist  no  longer  the 
ceaseless  infection.  He  took  the  Plague.  He  kept  on  work- 
ing. The  air  was  close  and  heavy.  The  windows  were  never 
open,  for  in  freezing  weather  fresh  air  costs  coal.  His  disease 
for  months  was  constantly  infecting  the  garments  he  worked 
on.     He  worked  until  the  very  end. 

On  the  floor  above,  the  right-hand  room  in  the  rear  has  one 
closet  bedroom  six  feet  by  seven.  An  Irish  boy  of  seventeen 
died  there  of  the  Plague  in  '96.  Soon  after,  a  man  of  forty- 
three  moved  in.  He  slept  in  the  same  closet.  One  year  later 
I  find  him  reported.  His  disease  was  slow.  He  kept  on  for 
two  years  with  his  work.  His  work  was  handling  fish  in  the 
market. 

In  the  basement   lived  another  man  who  made  hats.      He 

315 


died  of  the  Plague,  and  soon  after  the  basement  became  a 
pickle  factory.     So  it  is  to-day. 

In  the  front  house,  high  up  in  the  sloping  roof,  are  the  small 
dormer  windows  of  an  attic.  An  Italian  woman,  already  sick 
with  the  Plague,  moved  in  some  years  back,  with  a  wild, 
carousing  crowd  of  companions.  Three  weeks  of  this  brought 
the  end,  and  she  was  taken  off  in  the  ambulance.  The  attic 
is  now  offensive  beyond  words.  It  is  packed  with  some  twenty 
Italians— men  and  boys,  one  slight  girl  of  sixteen,  and  a  baby. 
The  men  bring  in  sheepskin  rugs  and  by  some  process  here 
make  them  snowy  white,  to  be  sold  up-town  from  house  to 
house,  where  they  bring  good  prices.     So  the  Plague  spreads. 

PLAGUE  SPOTS  IN  OTHER  CROWDED  QUARTERS 

This  is  infection  for  but  nine  years  in  one  tenement.  Not 
here  alone,  but  from  every  crowded  quarter,  these  stories  roll  up 
with  a  terrible  force.  I  give  briefly  the  stories  of  three  Plague 
rooms.  Up  on  West  Eighteenth  Street  is  one  room  in  a  rotten 
old  wooden  tenement.  For  years  it  has  held  the  same  dust  in 
its  corners,  the  same  grime  on  its  ceilings,  the  same  filth  on 
its  walls.  Sanitation  here  is  unspeakable.  The  Plague  entered 
by  chance  a  few  years  back.  It  was  no  chance  that  made  it 
stay.  Since  then  in  this  one  room  there  have  been  five  deaths 
from  the  Plague  among  those  who,  one  by  one,  have  come 
here  to  live,  who  have  been  weakened  by  its  foulness,  then 
infected  by  its  germs. 

Near  by,  on  Fifteenth  Street,  are  two  rooms  in  a  basement. 
These  are  damp  and  close  and  old  with  disease.  The  bedroom 
is  wholly  dark.  Here  the  Plague  came  in  three  years  back. 
A  man  died.  His  family  moved  out.  An  Irish  family  came 
next,  in  the  winter — "all  strong  and  well,"  the  dispensary 
doctor  said.  But  human  beings  to  keep  strong  need  more 
than  a  foul,  damp  basement.  Bodies  grow  weak ;  and  if  then 
the  germs  are  breathed  in  they  may  lodge  and  spread  with 
appalling  swiftness.  The  husband  took  the  Plague.  In  two 
months  he  died.     The  family,   now  weak  and  sickly,  moved 

316 


out  to  go  on  charity.  A  stout  German  moved  in  with  his  wife. 
Six  months  later  he  took  the  same  disease.  They  moved 
away.  An  Irish  widow  came  next.  She  was  the  strongest 
of  them  all.  The  four  little  children  were  lively  as  crickets. 
Soon  they  began  to  change ;  their  mother  began  to  cough. 
Now  she  is  dead  and  they  are  scattered. 

The  third  "home"  is  but  a  few  blocks  away.  The  family 
moved  in  some  three  years  back.  They  were  Americans — a 
young  man  of  thirty,  his  wife,  and  five  small  children.  One 
year  later  he  had  taken  the  Plague  and  died.  His  wife  slept  in 
the  same  back-room.  She  died  of  the  Plague  six  months  later. 
Her  old  father  and  mother  went  there  to  care  for  the  children. 
He  slept  in  the  same  back-room.  He  died  of  the  Plague  in 
1902.  His  son  came  to  help  support  the  others.  He  slept  in 
the  same  back-room.  Two  months  ago  he  died  of  the  same 
disease.  Of  these  cases  not  one  vv^as  reported  as  consumption. 
The  room  has  not  once  been  disinfected.  The  same  dirt,  the 
same  grime,  the  same  germs  are  undisturbed.  The  old  grand- 
mother is  there  now  with  the  children. 

THE   SERVANTS   OF   THE    SLAYER:    DARKNESS,    FOUL   AIR, 

IGNORANCE 

So  in  these  Plague  strongholds  infection  is  aided  by  dark- 
ness and  foul  air.  Of  these  two  evils — darkness  and  foul  air — 
there  are  many  causes. 

One  cause  is  the  air-shaft.  Through  the  city  are  thousands 
of  tenements  with  air-shafts  less  than  five  by  five.  Rooms 
opening  on  these  are  technically  "dark."  Add  these  to  the 
rooms  wholly  dark,  and  we  have  in  New  York  three  hundred 
and  sixty-one  thousand.  On  the  Lung  Block  alone  are  four 
hundred.  The  Tenement  House  Department  is  ordering  the 
landlords  all  over  the  city  to  open  up  one  side  of  each  dark 
closet,  so  making  a  huge  window  into  the  room  they  belong 
to,  that  more  light  and  air  may  thus  come  in.  There  are  three 
hundred  and  sixty-one  thousand  to  be  changed.  Meanwhile 
the  worst  Plague  strongholds  on  the  block  all  have  these  rooms 

317 


and  these  air-shafts.  Shafts  like  these  are  no  places  to  breathe 
in;  as  one  old  Irishman  said:  "They  do  for  wan  mouthful  of 
air  " — but  no  more.     The  sunlight  never  enters. 

I  know  a  winsome  little  chap  five  years  old,  and  his  name  is 
Yutzi  Romeo.  Two  years  back  his  father  came  over  from 
Sicily,  and  eight  months  ago  he  sent  for  the  little  wife  to  come 
and  bring  Yutzi.  I  found  them  in  a  rear  tenement  on  Hamil- 
ton Street,  one  where  the  Plague  has  made  a  fearful  record. 
They  lived  on  four  dollars  a  week,  in  a  room  and  a  bedroom 
closet.  Their  front  room  looks  into  a  court  five  floors  deep — 
a  court  so  narrow  that  a  short  iron  bridge  connects  the  two 
roofs  above  it.  The  closet  looks  on  an  air-shaft.  This  shaft 
is  two  feet  wide  by  fifty  deep;  foul  with  garbage,  decayed  ref- 
use, old  clothes,  and  filth.  The  dark  closet  has  a  window  high 
up,  small  and  gfated,  that  the  people  across  the  shaft  may  not 
crawl  in.  What  a  place  for  a  little  child  to  be  sick  in !  Here 
night  after  night  through  the  winter,  while  the  man  worked  in 
the  other  room  on  sweat-shop  garments,  the  little  mother  had 
sat  up  listening  to  the  cough  that  grew  deeper  and  more  chok- 
ing, watching  the  fever  grow  worse,  the  little  body  grow  thin ; 
frightened  more  each  night  as  the  neighbors  told  her  of  the 
Plague  and  what  it  could  do.  She,  too,  was  ignorant.  She 
bought  a  cheap  print  of  the  Madonna,  set  it  up  in  the  dark 
closet,  and  prayed  as  even  ignorant  mothers  can.  She  had 
tried  two  Italian  doctors.  I  tried  two  more.  "  Consumption 
— hopeless,"  said  both.  Then  we  went  up-town  to  a  great 
specialist  on  lungs — and  kindness.  He  said  at  last:  "Malaria 
and  bronchitis — will  almost  surely  develop  tuberculosis  in  such 
surroundings,  but  now  his  case  is  hopeful."  So  the  chance 
was  seized,  and  one  of  the  thousands  was  taken  in  time. 

There  are  hundreds  of  other  shafts  as  foul,  hundreds  of  other 
little  children  as  tender,  hundreds  of  other  mothers  who  love 
but  do  not  know. 

A  second  cause  of  foul  air  is  that  thousands  of  tenements 
have  no  skylights.  All  the  hot,  fetid  air  from  the  halls,  the 
stairs,  and  the  open  rooms  below  rises  up,  finds  no  way  out, 
and  settles  in  the  hall  and  rooms  above.     Time  and  again, 

318 


going  with  the  tenement  inspector,  I  felt  a  breath  of  bad  air  as 
we  reached  the  top  hallway.  This  complaint,  "no  skylight," 
was  sent  in  for  almost  every  house  on  the  block  where  the 
Plague  has  its  stronghold. 

I  remember  one  of  the  worst,  another  old  house  on  Hamil- 
ton Street,  with  eleven  cases  recorded  in  nine  years.  I  went 
in  one  night  at  six  o'clock.  Outside  was  broad  daylight.  I 
climbed  five  dark  flights,  felt  the  heavy,  foul  air  of  that  cramped 
top  hallway,  and,  groping  my  way  to  a  door,  I  knocked  and 
entered.  A  young  Irishman  of  twenty-five  lay  fevered, 
smothered,  breathing  hard,  in  a  tiny  room  stifling  hot.  His 
was  an  advanced  case  of  the  Plague.  Close  beside  his  lounge, 
on  a  soiled  pillow  on  a  chair,  lay  his  baby  girl  five  months  old, 
with  eyes  wide  and  frightened,  sick  with  pneumonia  and  the 
measles.  The  doctor  who  kept  the  drug  store  had  come  up 
once  to  see  her.  The  wife,  a  thin,  pale  girl  of  twenty-three, 
was  out  office  cleaning.  She  would  come  back  at  eight  o'clock, 
worn  out,  to  cook  and  clean  and  nurse.  Two  children  on  their 
floor  had  died  that  week  of  the  measles.  They  had  not  been 
reported.  The  man  kept  the  windows  all  shut  for  fear  of  his 
baby.  So  they  lay  side  by  side — white,  weak,  fighting  for 
every  breath.     And  every  breath  held  the  germs  of  the  Plague. 

Below,  on  the  ground  floor,  lay  a  man  of  twenty-nine,  a 
hopeless  case,  a  beast  from  drink  and  worse.  His  room  was  a 
pen  of  filth,  its  foul,  infected  air  mingled  with  that  of  the 
equally  infected  halls  and  stairways,  and  this  air  rose  up  to  the 
father  and  his  child.     So  it  is  with  thousands. 

There  are  many  other  causes  of  darkness  and  foul  air.  All 
these  I  can  show  best  by  a  story  of  a  case  in  "The  Bucket." 
In  the  fourth  floor  rear  lived  an  Italian  and  his  wife,  with  five 
small  children.  The  dark  man  was  a  hard  worker,  from  day- 
light until  long  after  dark,  sewing  neckties.  He  took  the 
Plague  in  a  tenement  near  by,  which  is  called  "The  Morgue  " 
because  in  the  past  fifteen  years  it  has  held  twenty-eight  cases 
of  the  Plague,  They  left  this  place  and  moved  up-town,  but 
could  not  bear  the  expense  and  so  came  down  to  this  tenement 
on  Cherry  Street.     The  man  was  sick  three  years,  still  working 

319 


when  he  could — infecting  the  ties  he  worked  on.  At  last  he 
stopped  and  went  to  the  hospital,  but  soon  left  and  came 
"home"  to  die.  It  is  this  love  of  wife  and  children  that  brings 
thousands  of  deaths  from  the  Plague  in  the  tenem.ents.  The 
man  died  in  the  spring  of  1902.     But  he  died  too  late. 

This  family  of  eight  had  lived  in  three  rooms.  One  was  a 
dark  closet,  windowless;  next  came  the  kitchen,  also  dark; 
and  third,  the  "best  room,"  crov/ded  with  old  plush  furniture, 
with  two  windows  looking  into  the  court  behind.  Here  the 
children  lived  with  the  father,  while  he  slowly  died. 

Here  the  air  was  forever  foul.  From  their  windows  the 
court  looks  like  a  deep  pit ;  brick  walls  rise  up  on  all  four 
sides.  It  is  crowded  below  with  school  sinks,  and  these  we 
found  unspeakably  filthy,  with  three  weazened  little  chaps 
playing  hide-and-seek  between  them.  The  ground  floor  of  the 
house  is  a  pork  shop,  where  huge  cauldrons  of  pork  fat  boil 
day  and  night.  Even  from  the  roof  above  we  noticed  the  sick- 
ening odor.  Inspecting  the  cellar  we  found  a  strange  odor  of 
gas.  The  floor  as  usual  was  damp,  uneven  earth.  A  huge  sewer 
main  ran  along  one  side.  In  this  we  found  three  gaps  the  size 
of  your  fist,  and  two  rents,  one  eighteen  inches  long;  hence 
the  odor,  which  mingled  with  the  other  odors  in  the  pit  outside. 

This  air  came  in  the  front  room,  through  the  dark  kitchen, 
into  the  closet  behind.  In  this  closet,  seven  feet  by  nine, 
slept  four  of  the  smaller  children.  Rosalie  was  a  gentle  little 
girl  of  seven.  At  night  she  slept  in  this  closet.  By  day  she 
watched  three  still  younger  brothers  and  sisters  while  her 
mother  was  out  scrubbing.  You  could  see  her  grow  paler 
each  day,  so  I  am  told  by  a  friend  from  the  settlement  near. 
It  was  then  her  father  came  home  to  die. 

That  was  a  terrible  month.  The  mother  never  let  the  four 
younger  children  go  down  to  the  street  below,  where  you  can 
see  men  and  women  drunk  at  any  hour,  where,  on  the  one 
block,  on  this  one  side  of  the  street  alone,  are  eight  saloons 
and  several  houses  of  ill-fame.  So  they  used  to  play  most 
often  in  the  hallways.  These  we  found  so  dark  that  it  took 
the  inspector's  lamp  to  show  up  the  filth  on  floors  and  stairs, 

320 


It  is  in  Halls  Like  These  that  the  Germs  Can  Live  Two  Years  or  Longer. 


An  Atr-shaft  Six  Feet  Long,  Twelve  Inches  Wide,  and  Six  Floors  Deep. 


the  broken  plaster,  the  grimy  streaks  and  patches  on  walls  and 
ceilings,  the  ideal  dark  hall  where  germs  live  two  years  and 
longer. 

The  father  died.  The  Italians  spend  every  cent  on  their 
funerals.  So  it  was  here.  Then  came  even  closer  living — and 
then  the  hot  weather.  The  four  brick  sides  of  their  pit  grew 
too  hot  to  cool  off  at  night.  All  night  you  could  hear  the 
coughing  from  two  consumptives  on  the  floor  just  below. 
"The  Bucket"  grew  terribly  thirsty;  noises  grew  louder  and 
more  prolonged.  Foul  air  arose  from  the  cellar,  the  pit,  the 
halls,  the  closet.  Rosalie  took  the  Plague  in  one  of  its  most 
loathsome  forms — intestinal  tuberculosis.  She  sank  swiftly. 
A  visiting  nurse  was  summoned,  and  found  the  child  lying  on 
two  chairs  near  the  two  open  windows.  "She  was  a  pitiful 
sight,  only  skin  over  bone."  She  could  barely  take  medicine. 
She  could  not  even  turn  over  unless  you  helped  her.  So  the 
weeks  dragged  on  while  the  foul  air  steamed  up.  In  the  end 
of  August  Rosalie  died. 

■    •  THE  WARFARE  AGAINST  THE  PLAGUE 

Congestion,  Dissipation,  Infection !  The  war  against  them 
will  be  fought  on  two  lines,  Prevention  and  Cure. 

Prevention  is  slow.  Foul  air,  darkness,  and  ignorance — these 
must  be  steadily  changed  for  fresh  air,  cleanliness,  knowledge, 
and  light.  It  means  years  of  unceasing  work  ahead :  unceas- 
ing work  by  the  new  Tenement  House  Department  which  in 
one  year  has  made  such  a  splendid  beginning;  unceasing  sup- 
port of  this  work  by  the  people  of  New  York;  unceasing  ap- 
propriations ;  unceasing  belief  that  to  save  thousands  of  human 
lives  is  cheap  at  any  cost.  It  means  millions  of  dollars  to  be 
spent  in  new  parks,  in  playgrounds,  in  public  baths.  It  means 
big-hearted  brotherhood.     It  means  self-defence. 

Cure  need  not  be  slow.  Those  sick  of  the  Plague  must  now 
be  treated  "at  the  right  time,  in  the  right  place,  in  the  right 
way,  till  they  're  cured" — not  as  before,  "at  the  wrong  time, 
in  the  wrong  place,  in  the  wrong  way,  till  they  're  dead." 

321 


In  Germany  every  laborer  and  servant  is  obliged  by  law  to 
become  insured  against  sickness,  accidents,  and  old  age,  the 
companies  being  controlled  by  the  government.  Hence,  as 
soon  as  the  Plague's  first  symptoms  appear,  men  are  quick  to 
find  relief  at  one  of  the  many  sanatoria.  There,  in  1897  and 
1898,  eighty-two  thousand  insured  men  and  women  were 
treated,  and  of  these  seventy-one  per  cent,  left  with  strength 
and  hope  won  back.  So  they  have  now  learned  to  hope;  and 
so  by  going  in  time  are  lastingly  cured.  Here  in  America  men 
wait  on  until  unable  to  work,  then  see  a  doctor,  and  at  last  are 
reported  hopeless.  The  cry,  "The  hopeless  report,  the  hopeful 
don't!  "  comes  from  all  the  men  and  women  who  are  striving 
to  push  this  tremendous  campaign.  I  give  now  the  reasons  for 
this  cry. 

FACTS  TO  BE  FACED  IN  NEW  YORK 

They  don't  report  in  time  because  the  places  of  cure  are  not 
yet  inspiring  trust  and  hope.  Go  to-night  through  this  same 
block.  You  will  find  no  one  sick.  They  must  know  you  first. 
What  is  your  business  there,  how  can  you  help?  In  my  week 
as  "fresh-air  man"  I  found  many  cases  before  unseen — because 
I  could  help.  The  city  has  even  now  room  for  but  a  few  hun- 
dred consumptives.  It  is  well  known  that  most  of  the  cases  it 
takes  are  already  hopeless.  True,  a  few  are  cured,  for  a  right 
beginning  has  already  been  made.  On  the  East  River  islands 
are  city  hospital  camps  which  are  doing  excellent  work.  At 
Seton  Hospital  a  few  more  are  cured  each  year.  This  is  just 
the  beginning. 

It  must  take  time  and  widespread  endeavor  to  kill  the  vague 
superstitions  that  have  grown  up  between  the  tenements  and 
the  city  hospital.  "The  black  bottle  "  I  have  heard  of  again 
and  again  as  containing  a  fatal  drug,  which  the  doctors  are 
believed  to  give  when  tired  of  free  patients.  So  thousands  are 
afraid  and  don't  report. 

They  don't  report  in  time  because  thousands  feel  that  the 
Plague  is  absolutely  fatal.     On  the  Lung  Block  two  hundred 

323 


and  sixty-five  have  been  sick;  hardly  one  has  been  cured. 
Those  sick  feel  the  Plague  fastening  slowly.  Many  make  up 
their  minds  to  die,  and  wait,  working. 

In  the  house  where  Rosalie  died  I  found  a  brave  little  woman 
working,  waiting  with  her  daughter  eight  years  old.  They  have 
a  room  looking  into  that  same  foul  pit ;  a  dark  kitchen  behind 
it,  where  the  gas  was  lit  when  I  went  in  at  noon ;  and  behind, 
wholly  dark,  a  bedroom.  In  this  room  her  mother  died  of  the 
Plague  eighteen  months  back.  Her  father  and  brother  both 
died  of  the  Plague  in  a  house  quite  as  bad  a  few  doors  up  the 
street.  Her  husband  was  already  stricken.  He  drank.  He  had 
left  her.  His  mother  and  father,  his  sister  and  two  brothers, 
had  all  died  of  the  Plague  over  on  Hamilton  Street.  And  now 
in  the  last  five  years  her  two  babies  had  died  from  another  form 
of  the  same  disease.  "What  's  the  use?  What  's  the  use?" 
While  her  mother  was  sick  she  was  working  through  the  sum- 
mer in  a  factory  from  7.30  in  the  morning  until  10.30  at  night. 
I  have  seen  such  places  in  summer.  A  hasty  swallow  at  noon 
and  six  o'clock;  between,  only  desperate  haste.  "The  steam 
was  the  worst,"  she  told  me;  "it  was  awful — awful — awful!  " 
The  few  hours  at  night  were  by  the  sick  mother.  In  a  few 
months  her  w^eakened  lungs,  too,  were  infected.  The  Plague 
fed  with  terrible  swiftness.  In  eight  months  she  lost  eighty- 
five  pounds- — but  still  worked  on.  At  last,  too  weak  for  the 
factory,  she  worked  from  seven  until  nine  and  again  from  five 
until  eight,  at  office  cleaning.  So  we  found  her  and  had  her 
examined.  The  doctor  said  there  was  still  a  chance.  And 
because  the  girl  of  eight  was  pale  and  delicate,  Ave  offered  to 
send  both  for  three  months  to  the  country,  where  medical  care 
could  be  given.  But  she  said:  "It  's  got  to  come  anyway,  an' 
we  'd  get  homesick  for  the  block,  so  I  guess  we  '11  stay." 

"It 's  got  to  come  !  " — this  is  the  belief  of  thousands.  This 
belief  can  only  be  destroyed  by  hundreds  of  cures  to  be  begun 
in  1903. 

They  don't  report  in  time  because  hundreds  are  insured  in 
small  companies,  and  this  insurance  is  all  lost  to  the  patient's 
family  if  his  disease  be  reported  as  consumption.      It  is  for  this 

323 


cause  that  thousands  have  died  of  the  Plague,  begging  their 
doctors  to  call  it  pneumonia  or  bronchitis.  Doctors,  too,  are 
human,  and  the  immediate  needs  of  their  patients  obscure  the 
importance  of  accurate  records.  So  thousands  have  died  in 
years  past  and  the  records,  startling  as  they  are,  have  not  yet 
told  the  whole  story. 

They  don't  report  in  time  because  they  want  to  live  to-day, 
not  after  six  months  of  tedious,  doubtful  recovery.  This  is 
most  true  of  the  Irish.  To-day  is  worth  a  score  of  to-morrows. 
Just  here  the  quack  steps  in  with  his  "Sure  Cure  for  Consump- 
tion." I  know  one  drug  store  on  Catharine  Street  where  the 
druggist  counted  from  memory  eighteen  who  had  come  to  hifti  ' 
regularly  for  these  patent  cures.  These  cures  contain  alcohol, 
which  brings  relief  to-day  but  relapse  to-morrow.  Their  writ- 
ten promises  are  vastly  more  attractive  than  the  vague  hopes 
held  out  by  the  doctors. 

The  druggist  told  me  of  one  tall,  genial  young  Irishman, 
barely  twenty  years  old,  who  came  every  week  for  three  months 
in  the  winter,  growing  steadily  more  emaciated,  his  eyes  more 
hopeless,  his  jokes  more  feeble,  his  smile  more  forced.  At 
last  he  disappeared.  So  it  has  been  with  not  hundreds  but 
thousands  here  in  the  city  who  have  spent  their  small  earnings, 
their  small  hope,  in  these  cheap  deceptions,  have  lost  faith  in 
all  medical  aid,  and  so  despairing  have  died. 

One  reason  why  the  Plague  makes  such  slow  progress  among 
the  Jews  is  their  constant  effort  to  cure  it  in  the  right  way — by 
fresh  air,  by  right  and  abundant  food.  I  know  of  one  family 
with  five  small  children  where  every  cent  was  scraped  and 
saved  from  the  push-cart  earnings  in  the  Ghetto  to  send  the 
father  back  to  Germany  to  a  sanatorium  there.  This  happens, 
I  am  told,  with  hundreds  in  our  Ghetto. 

Up  on  Second  Avenue  lives  a  Polish  widow.  She  has  two 
babies,  two  and  three  years  old,  and  she  has  taken  the  Plague. 
She  is  only  an  ignorant  mother.  Being  ignorant,  she  cannot 
see  the  danger,  nor  the  use  of  carbolic  acid.  Being  a  mother, 
she  sleeps  with  them,  feeds  them,  loves  them.  To  leave  the 
wretched  small  room,  the  unchecked  fever,  the  aching  weari- 

324 


ness  of  sleepless  nights,  to  leave  all  this — and  the  babies — she 
has  twice  refused.  And  up  on  East  Sixteenth  Street  there 
lives  a  Russian  sick  of  the  Plague.  All  day  and  long  into  the 
night  he  sat  sewing  garments  in  the  one  small  room.  His  little 
daughter  of  twelve  worked  with  him.  Now  she,  too,  has  taken 
the  Plague.  Again  and  again  have  friends  tried  to  give  her 
these  summer  months  in  the  country.  But  her  father  is  sick 
and  alone.     So  she,  too,  stayed  on — and  now  she  is  dying. 

They  don't  report  in  time  because — and  this  last  reason  is 
strongest  of  all — they  won't  give  up.  Life  in  the  tenements 
is  bright  and  full  of  color  if  only  you  keep  up.  Lose  your 
grip,  and  things  seem  to  pile  up  in  a  day  and  bury  you  under. 
All  who  watch  the  tenements  will  tell  you  this.  "Don't  lose 
your  grip!  "  is  the  motto.  Charity  experts  agree  that  here  in 
America  the  dread  of  going  on  charity  is  generally  greater  than 
in  any  other  country  of  the  earth.  And  so  they  fight  on,  be- 
cause plucky,  and  because  they  have  seen  their  Plague-stricken 
friends  go  to  the  hospitals  only  to  die.  They  keep  clear  and 
won't  believe  in  time.  They  fight  bn  blindly.  I  remember 
case  after  case  of  brave,  unceasing  effort,  of  kindness,  devotion, 
and  death.  Most  of  it  is  blind  for  all  the  reasons  I  have  given, 
and  because  there  is  hardly  a  case  that  can  be  cured  without 
large  expense  of  money. 

I  am  glad  to  tell  of  one  case  where  the  unaided  struggle  was 
won,  in  a  rotten  old  tenement  on  Cherry  Street.  Husband 
and  wife,  Danish,  they  had  lived  on  the  block  for  sixteen  years. 
The  man  was  pronounced  hopeless  last  December.  Then  his 
wife  took  charge.  Years  ago,  as  a  nurse  in  the  English  army, 
she  had  fought  day  and  night  the  fearful  cholera  plague  in 
India.  She  was  iron-strong  in  mind  and  body  and  soul.  For 
three  days,  she  told  me,  she  "talked  the  Plague  right  out  of 
him."  First — all  doctors  were  fools  !  Second — he  was  a 
coward!  Third — he  nmst  get  well!  She  had  sent  to  D.en- 
mark  for  a  wonderful  herb  which  her  old  mother  had  used, 
and  for  some  Danish  sweet  oil.  She  brought  out  now  every 
cent  of  her  savings.  Milk  and  eggs,  meat  soups  and  oil — all 
these  were  given   constantly.     He  was    moved   to   a  lounge 

325 


right  under  the  open  windows.  He  was  never  left  alone. 
The  Plague  was  talked  out,  oiled  out,  herbed  out.  Perhaps 
the  milk  and  eggs  and  the  unceasing  devotion  did  it.  He 
gained  twenty  pounds,  and  is  now  again  out  working — ten 
hours  a  day  cleaning  out  manholes. 

This  success  is  but  one  among  thousands  of  failures.  Across 
the  street,  in  "The  Barracks,"  a  woman  told  me  that  for  weeks 
she  had  been  kept  awake  in  her  closet  bedroom  by  an  unending 
cough  that  came  through  the  thin  partition  beside  her.  It  was 
some  time  until  I  found  the  one  who  coughed,  because  she 
worked  all  day.  She  was  a  German  widow  whose  husband 
died  of  the  Plague  last  year.  She  has  three  children,  one  a 
baby  in  the  day  nursery.  She  comes  home  only  late  at  night. 
At  first  she  was  afraid  to  be  examined,  and  it  was  only  through 
the  kindness  of  the  doctor  at  the  mission  near  by  that  this 
strong  fear  was  overcome.  The  woman  had  the  Plague  in  the 
very  beginning  stage.  She  might  easily  be  cured.  She  was 
told  she  might  take  her  baby  and  youngest  boy  to  the  country 
to  be  boarded  free  all  summer.  The  boy  of  fourteen  was  to 
be  kept  with  friends  until  she  came  back  in  the  fall.  She  re- 
fused. She  thought  work  was  too  rare  to  be  given  up ;  what 
if  she  could  find  no  other  work  in  the  fall  and  so  go  on  charity? 
Anyway,  she  was  n't  yet  sick.  She  would  work  on,  she  said, 
until  she  got  sick  in  bed,  and  then  she  would  think  of  being 
cured.  No  arguments  from  visitor,  doctor,  or  friends  could 
change  this  decision.  "Keep  your  grip  !  "  It  is  the  motto  of 
America. 

WHAT  THE  SITUATION  DEMANDS 

The  right  time,  the  right  place,  the  right  way,  are  all  de- 
manded. The  sick  will  never  report  at  the  right  time  until 
they  believe  they  can  be  healed ;  until  they  know  we  have  the 
right  ways  and  the  right  places  to  cure  them.  These  right 
places  must  now  be  made. 

Millions  must  be  spent — because  thousands  of  human  lives 
will  not  be  saved  for  less.  Most  doctors  agree  that  every  con- 
sumptive should  be  taken  outside  the  city  to  sanatoria.     All 

326 


doctors  agree  that  there  are  thousands  in  the  most  wretched 
of  our  tenements  who  cannot  possibly  be  cured  in  their  present 
foul  surroundings.  As  one  has  said  :  "  It  is  open  air,  and  open 
air  all  the  time,  that  counts."  He  adds:  "The  Plague  is  not 
cured  by  quacks,  by  patent  medicines,  nostrums,  or  other 
secret  remedies ;  but  solely  and  exclusively  by  scientific  and 
judicial  use  of  fresh  air,  sunshine,  water,  abundant  and  good 
food ;  milk,  eggs,  meat,  vegetables,  fruit ;  and  by  the  help  of 
certain  medical  substances  when  these  hygienic  and  dietetic 
means  do  not  suffice  in  themselves  to  combat  the  disease." 

The  farm  cure  plain  and  simple  is  not  enough.  A  friend  of 
mine  sent  one  young  Russian  to  a  farm  last  March  to  be  cured 
by  Nature.  The  Plague  was  only  beginning.  The  time  was 
right ;  the  place  was  wrong.  At  the  end  of  a  month  a  series 
of  letters  began,  of  which  I  quote  bits  that  tell  the  whole  story : 
"i  am  improving  very  nice — i  aint  coughing  no  more — i  am 
getting  fat — i  sleep  good  and  i  have  a  good  appetite  to  eat — i 
gained  sixteen  pounds — the  country  doctor  here  says  the  only 
thing  i  Need  is  plenty  of  exercise  ivork  all  day  plozving  and 
planting  on  the  farm — so  i  do.  when  i  earn  enough  i  will 
bring  my  wife  and  baby — it  is  a  regular  paradise — i  will  live 
here  always — the  faivers  you  have  done  to  me  will  never  be 
forgotten."  Two  weeks  later:  "you  write  me  not  to  work 
hard,  you  no  as  long  as  i  am  harnest  up  i  must  pull — my  wife 
and  baby  are  here  and  feel  good — i  will  answer  your  questions 
— i  cough  again  bad — appetite  no  good — sleep  no  good — sweat 
nights  no — fever  yes. ' '  Ten  days  later :  "  i  am  coughing  some- 
thing terrible  werst  i  ever  did."     He  died. 

He  should  not  have  died !  And  now  others  like  him  must 
live.  We  must  have  the  right  places ;  where  not  in  summer 
alone  but  all  through  the  winter  the  sick  may  have  the  right 
use  of  fresh  air  and  sunshine;  where  the  right  food  may  be 
given  in  abundance;  where  doctors  will  not  advise  "heavy 
plowing  all  day" ;  but  where  the  riglit  doctors  and  nurses  will 
ever  watch  and  heal. 

Millions  must  be  spent  because  it  is  sound  common-sense, 
because  these  few  millions  will  save  to  the  city  countless  mil- 

327 


lions  more.  Dr.  Biggs  of  the  Health  Department  has  esti- 
mated that  the  total  loss  to  New  York  City  alone  from  this 
Plague  is  at  least  twenty-three  millions  of  dollars  a  year,  and 
that  the  loss  to  the  United  States  must  be  over  three  hundred 
and  thirty  millions.  Why?  The  Plague  attacks  young  men 
most  of  all.  The  average  cost  to  society  of  a  man's  bringing 
up  is  fifteen  hundred  dollars.  This  loan  he  returns  by  the 
labor  of  his  manhood.  Multiply  this  by  the  thousands  of 
young  men  who  die  each  year  of  the  Plague  in  New  York 
alone.  To  this  loss  you  must  add  millions  more  for  the  care 
and  expense  they  require  from  families  or  friends  or  the  city, 
in  their  lingering  illness.  It  costs  each  patient  several  hundred 
dollars  to  die.  And  add  still  more.  For,  as  was  recently 
said,  the  Plague,  because  so  lingering  and  hence  so  costly,  be- 
cause it  attacks  most  often  the  breadwinner  of  the  family,  is 
"a  cause  of  poverty  out  of  all  proportion  to  its  importance  as 
a  cause  of  death."  Wives  and  children  are  forced  on  charity 
lists. 

And  so  each  year  the  expense  rolls  up  into  the  millions. 
We  are  told  that  five  millions  wisely  used  now  for  great  sana- 
toria, for  more  dispensaries  and  diet  stations,  for  more  in- 
spectors, would  save  countless  millions  to  be  lost  year  after 
year  in  the  future. 

What  has  been  spent  before  has  been  mostly  useless.  Four 
per  cent,  of  the  tenement  consumptives  have  gone  to  hospitals 
— most  of  them  to  die,  and  for  lack  of  room  many  have  gone 
into  the  wards  with  other  patients.  This  four  per  cent,  has 
cost  the  city  five  hundred  thousand  a  year  without  propor- 
tionate result.  "Treble  this  sum,"  says  Dr.  Knopf,  "and 
thousands  of  lives  may  be  saved  annually."  Not  only  will 
these  lives  be  saved ;  they  will  cease  to  be  a  menace  to  others. 

The  old  treatment  in  the  hospitals  was  as  costly  as  it  was 
useless.  In  one  recent  year  seventeen  hundred  and  fifty  died 
in  the  public  hospitals  of  the  city.  Careful  calculation  shows 
that  these,  if  treated  in  sanatoria,  would  have  cost  the  city 
four  dollars  a  week  less  for  each  patient.  It  is  the  same  among 
children.     The  need  for  seaside  sanatoria  for  little  children 

328 


whom  the  Plague  has  attacked  in  other  forms — this  need  is 
appalling.  In  such  places  thousands  like  Rosalie  might  have 
been  cured.  On  the  coasts  of  Germany,  France,  Italy,  Hol- 
land, thousands  of  lives  have  so  been  saved.  Over  here,  our 
Plague-stricken  children,  if  cared  for  at  all,  are  kept  in  city 
hospitals  at  an  expense  far  greater,  with  suffering  far  worse. 

Millions  must  be  spent  because  hundreds  of  thousands  from 
every  class  in  the  city  are  in  constant  danger.  As  Dr.  Knopf 
has  said,  the  patient  up  and  about,  attending  often  to  his  usual 
work,  but  expectorating  indiscriminately  everywhere  from 
ignorance  or  carelessness,  is  the  most  dangerous  of  all  con- 
sumptives. You  have  heard  stories  of  how  the  sick  struggle 
on.  In  laundry,  cigar  factory,  cook  shop,  fish  market ;  as 
waiter,  as  midwife ;  in  scores  of  callings  they  have  worked  on 
and  coughed  and  worked  on  still,  infecting  their  fellows  and 
the  products  of  their  labor.  Of  these  the  sweat-shop  work  is 
most  dangerous,  most  potent  to  spread  the  Plague  to  all 
classes.  It  is  an  open  fact  that  most  tailors  from  every  class 
put  their  work  out  to  be  done  in  the  sweat-shop  or  in  the  tene- 
ment home.     The  home  itself  becomes  then  a  sweat-shop. 

In  a  row  of  fifteen  old  houses  on  Cherry  Street  I  found 
thirty-one  little  children  and  eighty-seven  women  sewing  on 
garments.  The  garments  they  sewed  were  almost  all  to  be 
worn  by  young  children — the  kind  you  buy  in  our  clothing 
stores.  This  row  of  fifteen  houses  included  the  five  most 
deadly  Plague  strongholds  on  the  block. 

This  home  work  shows  most  clearly  what  is  true  in  some 
degree  in  all  other  trades — that  the  Plague-stricken  poor  must 
work  on  to  the  very  end.  You  have  had  stories  enough.  I 
will  add  but  a  scene  taken  from  the  written  records  of  a  visit- 
ing nurse. 

The  man  was  dying  down  in  the  Ghetto.  His  cough  kept 
on  day  and  night.  It  was  January.  Coal  was  high.  The 
room  at  night  grew  freezing  cold.  The  Plague  grew  worse. 
He  worked  on  in  bed.  He  had  but  one  blanket.  He  used 
the  coats  and  trousers  to  cover  him.  Now  consider  our  tense, 
rushing,  strained  city  life ;  remember  the  scores  of  your  own 

329 


friends  whose  vitality  is  now  at  the  lowest  ebb ;  and  then 
think  of  the  constant  danger  to  them  from  a  Plague  whose 
victims  keep  on  working,  who  are  constantly  in  the  streets, 
the  cars,  and  all  public  places.  We  all  use  the  products  of 
their  work.  Only  be  human  and  think  of  these  hundreds  of 
thousands,  rich  and  poor  alike,  in  constant  danger.  Thou- 
sands of  these  will  inevitably  be  taken  with  the  Plague  this 
year,  as  thousands  were  taken  last  year  and  before.  It  is  for 
next  year,  the  next,  and  the  next,  that  I  appeal. 

Millions  must  be  spent — because  we  are  human.  It  is  my 
last  word.  It  holds  all  the  rest.  I  once  heard  a  little  chap 
uptown  on  his  knees  at  night  whispering,  "Give  us  this  day 
our  daily  bread."  He  stopped  and  asked,  "How  many  is 
us?  "  From  a  visiting  nurse  I  heard  of  another.  He  was  four 
years  old,  in  a  tenement  room,  and  dying.  The  Plague  had 
gone  all  through  his  weak  little  body.  The  eyes  were  blind. 
And  each  night,  when  her  half-hour  visit  was  ended,  he  used 
to  grope  for  her  hand  to  hold  it  just  a  moment,  that  it  might 
help  him  bear  the  long  night.  This  baby  might  have  been 
saved.  He  is  one  cost  of  delay.  The  weak  groping  hand 
seemed  to  ask  the  same  question,  "How  many  is  us?  "  And 
this  is  the  answer : 

"I  was  an  hungered  and  ye  gave  me  meat :  I  was  thirsty,  and 
ye  gave  me  drink :  I  was  a  stranger,  and  ye  took  me  in : 
naked,  and  ye  clothed  me :  I  was  sick,  and  ye  visited  me :  I 
was  in  prison,  and  ye  came  unto  me.  .  .  .  Inasmuch  as 
ye  have  done  it  unto  one  of  the  least  of  these  my  brethren,  ye 
have  done  it  unto  me." 


330 


Appendix  17 

THE  MANAGEMENT  OF  CASES  OF 

PULMONARY  TUBERCULOSIS 

IN  THE  DISPENSARY 

By  JAMES  ALEXANDER  MILLER,   A.M.,   M.D. 

CLINICAL  ASSISTANT  IN  THE  VANDERBILT  CLINIC 
NEW  YORK 

Reprinted,  with  permission,  from  Medical  Record 


331 


THE    MANAGEMENT  OF  CASES  OF   PULMONARY 
TUBERCULOSIS    IN    THE   DISPENSARY 

The  problem  which  here  confronts  us  is  a  very  familiar  one 
to  all  who  have  had  any  experience  in  medical  dispensary 
work.  It  is  a  very  general  opinion  that  these  cases  of  pulmo- 
nary tuberculosis  are  the  most  discouraging  and  the  most  hope- 
less, as  well  as  the  most  common,  with  which  the  dispensary 
physician  has  to  deal. 

That  interest  in  them  should,  therefore,  be  comparatively 
slight  is  very  natural,  and  we  need  not  be  surprised  to  find  it 
confined  largely  to  sympathy  for  their  misfortune  and  curiosity 
as  to  their  physical  signs. 

The  first  thought  is  to  send  these  patients  to  the  country, 
and  when  this  is  found  to  be  impracticable,  their  treatment 
settles  into  a  perfunctory  routine,  and  the  patient  subsides 
into  the  dreary  dispensary  habit,  encouraged  only  by  the  hopes 
arising  from  a  strange  optimism. 

We  are  hearing  a  great  deal  nowadays  of  the  "Combat  with 
Tuberculosis,"  and  there  certainly  is  a  scientific  and  philan- 
thropic interest  in  this  disease  more  widespread  than  at  any 
previous  time.  Its  terrifying  prevalence  is  at  least  becoming 
recognized,  and  the  hope  of  an  absolute  recovery  from  it  in 
favorable  cases  has  been  better  established.  Our  knowledge 
of  the  conditions  under  which  it  thrives,  and,  on  the  other 
hand,  of  the  requirements  necessary  for  its  prevention  and 
cure,  has  been  widely  extended.  Results  of  such  increased 
knowledge  must   surely  follow,   and  we  see  them  already  in 

333 


more  efficient  sanitary  legislation,  in  tenement-house  reform, 
in  lectures  and  circulars  for  the  education  of  the  people,  in 
a  constantly  increasing  number  of  sanatoria  and  hospitals  for 
these  patients,  and  in  organizations  especially  designed  to 
investigate  and  prevent  the  spread  of  this  disease. 

All  of  this  work  should  be  heartily  supported  and  extended 
as  far  as  possible,  and  no  one  can  fail  to  appreciate  the  enor- 
mous importance  of  sustained  efforts  in  these  directions. 

In  the  struggle  against  tuberculosis  there  is,  however,  one 
weak  point  in  the  plan  of  attack,  as  it  has  been  thus  far  de- 
veloped. This,  it  appears  to  me,  is  the  unfortunate  state  of 
affairs  existing  in  the  dispensaries,  in  regard  to  these  patients. 
That  the  dispensary  treatment  of  these  cases  in  New  York 
City  is  almost  universally  unsatisfactory,  both  to  the  patients 
and  to  the  physicians,  will,  I  think,  be  very  generally  conceded 
without  further  discussion.  With  two  or  three  exceptions, 
there  is  no  especial  care  or  attention  given  to  these  patients  in 
any  dispensary  of  the  city.  At  the  Post-Graduate  Hospital 
an  excellent  work  is  being  done,  the  published  reports  of  which 
give  very  satisfactory  grounds  for  congratulation  on  the  part 
of  those  directly  interested  in  it,  and  for  encouragement  to 
those  who  may  hope  for  equally  good  results  along  similar 
lines  in  other  institutions.  It  appears  to  us,  however,  that 
even  this  most  excellent  work  can  be  very  materially  widened 
in  its  scope  when  it  is  applied  to  dispensaries  in  general.  We 
believe  that  the  responsibility  of  the  proper  dispensary  man- 
agement of  pulmonary  tuberculosis  should  not  cease  with  the 
marked  improvement  in  health  of  a  selected  number  of  such 
patients,  but  should  include  every  patient  who  applies  for 
treatment,  and  should  extend  also  to  a  strict  regulation  and 
supervision  of  the  home  surroundings  and  personal  habits  of 
all  these  patients.  In  this  way  the  spread  of  this  disease  may 
be  more  effectually  checked,  and  the  patient,  with  all  his 
family,  enter  into  cordial  and  intelligent  co-operation  with  the 
efforts  which  are  exerted  in  his  behalf. 

Since  the  beginning  of  the  current  year  an  attempt  has  been 
made  upon  a  gradually  increasing  scale  to   carry  out   these 

334 


ideas  at  the  Vanderbilt  Clinic,  It  is  the  object  of  this  com- 
munication to  describe  these  efforts  in  some  detail,  and  to  give 
a  preliminary  report  of  the  results  thus  far  obtained. 

At  the  very  outset  it  must  be  understood  that  we  are  here 
dealing  solely  with  those  patients  who,  for  one  reason  or  an- 
other, are  unable  to  avail  themselves  of  what  is  generally 
acknowledged  to  be  the  ideal  treatment  of  their  disease.  We 
now  know  this  to  be  an  open-air  life,  in  a  favorable  climate, 
with  freedom  from  actual  physical  or  mental  exertion,  an 
abundance  of  the  most  nourishing  food,  and  under  the  careful 
supervision  of  an  experienced  medical  adviser.  All  of  these 
conditions  we  find  only  in  a  well-conducted  sanatorium.  Such 
sanatoria,  however,  are  unfortunately  so  inadequate  in  number 
and  in  size,  and  are  regulated  by  such  stringent  requirements 
for  admission,  that  we  actually  find  the  whole  great  mass  of 
the  tuberculous  poor,  for  whom  there  is  no  provision,  relying 
upon  the  dispensaries  for  whatever  medical  attention  they  may 
receive. 

When  this  fact  is  taken  into  proper  consideration,  the  great 
importance  of  making  this  dispensary  treatment  as  effectual 
and  careful  as  possible  is  apparent  to  all  who  are  interested  in 
the  eventual  solution  of  this  great  tuberculosis  problem.  That 
such  is  not  the  condition  of  affairs  at  present  may  be  gathered 
from  what  has  already  been  said,  and  from  the  general  experi- 
ence of  all  physicians  active  in  dispensary  work. 

It  is  the  aim  and  purpose  of  the  present  movement  instituted 
at  the  Vanderbilt  Clinic,  to  at  least  make  a  beginning  in  the 
right  direction,  and  gradually  to  develop  a  careful  and  intelli- 
gent system  of  management  of  these  cases  of  tuberculosis, 
until  such  time  when  public  and  private  philanthropy  shall 
have  provided  sufficient  sanatoria  to  accommodate  all  such 
patients,  and  thus  relieve  us  of  our  responsibility  toward  them. 
In  spite  of  the  very  considerable  activity  now  being  directed 
toward  that  end,  we  can  not  but  realize  that  the  prospect  of 
any  such  happy  state  of  affairs  is  still  very  remote.  We  offer 
our  plan  as  a  practical  suggestion  to  dispensary  physicians,  in 
the  firm  conviction  that  it  is  possible  so  to  improve  upon  our 

335 


ordinary  methods  of  management  in  such  cases,  that  marked 
results  will  be  shown  in  the  condition  of  the  patients,  in  the 
diminished  dangers  of  transmission  of  the  disease,  and  in  the 
increasing  interest  afforded  to  the  attending  physician.  More- 
over, we  hope  to  demonstrate  that  these  results  may  be  ob- 
tained with  very  little  increased  expense  on  the  part  of  the 
dispensary,  and  that,  therefore,  no  available  funds  will  be 
diverted  from  the  cause  of  new  sanatoria. 

We  will  consider  our  subject  under  two  main  divisions:  (i) 
The  treatment  of  the  patient.  (2)  The  inspection  and  regula- 
tion of  the  homes. 

The  Treatme7it  of  the  Patient. — After  it  is  decided  in  each 
individual  case  that  proper  sanatorium  or  hospital  treatment 
is  not  practicable,  we  accept  the  responsibility  of  its  manage- 
ment, and  our  general  plan  is,  as  far  as  possible,  to  adapt  sana- 
torium methods  to  the  conditions  existing  at  home. 

A  thorough  mutual  understanding  between  physician  and 
patient  is  essential  at  the  very  outset,  for  in  no  other  way  can 
the  necessary  co-operation  be  secured. 

The  patient  should  be  informed  of  the  nature  of  his  disease, 
and  every  legitimate  encouragement  for  ultimate  recovery 
should  be  given  him,  but  never  should  he  be  allowed  to  forget 
the  seriousness  of  the  situation.  A  false  sense  of  security  is 
very  dangerous,  but  very  common  among  these  patients,  and 
especially  is  this  true  of  the  early  cases  in  young  people,  whose 
symptoms  are  so  slight  that  they  find  it  very  hard  to  realize 
the  underlying  dangerous  possibilities. 

Discouragement,  even  to  extreme  mental  depression,  is  also 
very  frequent,  and  the  appreciation  and  proper  management 
of  the  state  of  mind  in  each  patient  is  very  essential  to  their 
successful  treatment.  The  danger  of  infection  must  be  care- 
fully explained,  but  emphasis  should  be  placed  upon  the  fact 
that  all  such  dangers  may  be  avoided  by  the  proper  care  of  the 
expectoration.  In  the  Vanderbilt  Clinic  each  patient  is  sup- 
plied with  suitable  pocket  cuspidors,  which  have  been  especially 
devised  for  our  purpose,  and  they  are  also  given  printed  circu- 
lars of  information  concerning  their  disease  and  the  general 

336 


principles  of  its  treatment.  The  important  points  are  ex- 
plained carefully  to  each  patient,  and  upon  the  results  of  this 
first  talk  will,  very  often,  depend  what  sort  of  a  patient  he  is  to 
make,  and,  therefore,  the  importance  of  devoting  time  and 
thoughtful  attention  to  it  cannot  be  too  strongly  emphasized. 

The  actual  treatment  rests  upon  four  underlying  principles: 
(i)  Rest,  (2)  Fresh  Air,  (3)  Food,  (4)  Drugs. 

The  application  of  these  principles  to  the  treatment  of  tuber- 
culosis in  general  is  too  well  known  to  require  repetition,  but 
the  modifications  of  them  which  are  necessary  in  our  dispensary 
dilemma  will  here  be  considered. 

Rest. — Among  the  people  of  this  class,  freedom  from  physi- 
cal exertion  is  unknown  and  generally  is  impossible.  They 
must  live,  and  in  order  to  live  they  must  work.  This  is  a 
proposition  which  admits  of  very  little  argument.  Rest,  how- 
ever, is  a  comparative  term,  and  there  is  seldom  a  case  in 
which  a  great  deal  more  of  it  may  not  be  introduced  into  the 
daily  routine  than  has  heretofore  been  customary.  If  the 
disease  is  in  an  active  stage,  it  is  of  the  greatest  advantage  to 
give  the  patient  at  least  two  weeks  of  absolute  rest,  and  if 
there  is  fever,  this  rest  should  be  strictly  in  bed.  In  other 
cases,  an  easy  or  reclining  chair  on  the  fire-escape  or  roof  is  a 
very  satisfactory  method  of  obtaining  rest  in  the  open  air. 

The  effect  of  even  so  short  a  time  as  two  weeks  spent  in  this 
way  is  often  remarkable,  and  is  shown  by  the  subsidence  of 
the  fever  and  by  the  general  improvement  of  the  patient ; 
moreover,  there  are  comparatively  few  patients  who  are  not 
able  and  willing  to  give  up  this  time  for  that  purpose.  When 
the  time  comes  that  they  must  resume  work,  they  are  in- 
structed to  avoid  all  unnecessary  exertion  or  exercise,  to  rest 
at  odd  moments  whenever  possible,  and  to  rest  absolutely 
after  working  hours.  Whenever  the  character  of  their  work 
is  evidently  having  an  injurious  effect,  a  change  of  occupation 
is  advised,  and,  if  possible,  actual  assistance  is  rendered  toward 
that  end.  Employment  requiring  little  physical  exertion,  and 
preferably  in  the  open  air,  is  the  condition  desired,  and  several 
of  our  patients  have  secured  positions  as  watchmen,  janitors, 

337 


ticket  choppers,  transfer  agents,  etc.,  as  the  result  of  our  ad- 
vice. All  patients  are  instructed  to  cest  in  the  open  air  as  much 
as  possible,  to  avoid  exercise  which  produces  fatigue  or  short- 
ness of  breath,  and  to  spend  from  eight  to  ten  hours  of  each 
twenty-four  in  bed.  When  a  determined  effort  is  made,  it  is 
often  possible  to  effect  a  very  fair  "rest  cure,"  even  while  a 
patient  is  engaged  in  active  occupation,  and,  perhaps,  support- 
ing a  family. 

Fresh  Air. — Methods  of  obtaining  fresh  air  in  connection 
with  rest  have  already  been  mentioned.  In  addition,  the  pa- 
tient should  sleep  in  the  lightest  and  best  ventilated  room  of 
the  home,  and,  when  practicable,  he  should  be  its  sole  occu- 
pant. In  any  case  a  separate  bed  is  absolutely  essential. 
This  bed  should  be  so  placed  that  draughts  will  be  avoided, 
and  the  window  should  be  kept  open  continually,  provided 
that  the  bed  covering  is  sufficient  to  keep  the  patient  warm. 
By  means  of  an  inexpensive  steamer  chair  and  suitable  wraps, 
the  patient  may  rest  out-of-doors,  on  the  roof  or  fire-escapes, 
very  comfortably,  and:  should  sleep  there  during  the  summer 
months.  The  nearest  park  should  be  utilized  in  favorable 
weather,  as  opportunity  offers,  and  all  crowded  places  of 
amusement  or  wherever  bad  ventilation  might  be  expected 
should  be  avoided.  There  is  a  growing  sentiment  that  the 
value  of  any  particular  climate  in  the  treatment  of  pulmonary 
tuberculosis  has  been  greatly  exaggerated.  While  we  are  not  yet 
disposed  to  think  of  New  York  City  as  an  ideal  health  resort, 
nevertheless,  the  open  air  even  here  is  certainly  beneficial,  and 
we  should  endeavor  to  make  every  possible  use  of  it  for  these 
cases.  In  this  connection  there  is  need  to  protest  against  in- 
discriminately sending  consumptives  to  the  country,  for  many 
localities  previously  free  from  this  disease  have  become  in- 
fected by  such  patients,  who  have  been  ignorant  or  untrained 
in  the  necessary  sanitary  precautions.  No  patient  should  be 
sent  away,  unless  placed  under  the  direct  supervision  of  a  com- 
petent physician,  until  he  has  demonstrated  his  willingness  and 
ability  to  properly  respect  the  health  of  others. 

Food. — This  aspect  of  the  question  is  very  important   but 

338 


often  very  troublesome  in  our  work.  Gastric  disturbances  are 
such  a  marked  feature  of  this  disease  that,  even  under  the  best 
of  conditions,  proper  digestion  and  assimilation  are  often  diffi- 
cult to  obtain.  When  to  this  difficulty  is  added  the  inability 
to  pay  for  proper  food,  and  the  wretched  cooking  of  that 
which  is  procured,  the  condition  of  affairs,  as  regards  many  of 
our  patients,  is  accurately  described.  Our  first  object  should 
be  to  correct  any  digestive  disturbance.  Rest  is  again  a  valu- 
able aid  here,  and  by  careful  and  judicious  regulation  of  the 
diet  good  results  may  generally  be  obtained.  Much  harm  is 
often  done  by  overfeeding  before  the  digestive  system  is  prop- 
erly prepared  for  it,  and  we  should  carefully  and  gradually  feel 
our  way,  until  the  desired  condition  of  a  good  appetite  and  a 
perfect  digestion  of  a  large  abundance  of  food  is  obtained. 

For  purposes  of  superalimentation,  milk  and  raw  eggs  are 
the  best  articles  of  diet.  We  gradually  accustom  our  patients 
to  the  ingestion  of  two  or  three  quarts  of  milk  and  from  six 
to  ten  raw  eggs  every  day,  in  addition  to  a  regular  diet  of 
simple  food. 

The  increased  expense  which  this  involves  is  considerable, 
but  many  of  our  patients  are  able  to  meet  it.  How  best  to 
supply  those  patients  who  are  unable  to  do  so  for  themselves 
is  a  question  that  has  occupied  a  great  deal  of  thought  and 
attention.  '  We  have  attempted  arrangements  with  the  Diet 
Kitchen  and  with  grocers,  by  which  fresh  milk  and  eggs  should 
be  delivered  to  our  patients  at  reduced  rates,  but  the  practical 
operation  of  these  arrangements  has  not  been  satisfactory. 

It  is  our  habit  at  present  to  report  all  these  cases  to  the 
Committee  of  the  Charity  Organization  Society  for  the  Pre- 
vention of  Tuberculosis,  and  up  to  this  time  they  have  been 
able  to  supply  all  such  patients  according  to  the  necessity 
existing  in  each  instance.  Our  experience  leads  us  to  believe 
that  this  plan  will  be  found  more  satisfactory  than  for  the 
dispensary  to  attempt  an  independent  means  of  supply  for  its 
own  patients,  and  it  has  the  compensating  advantage  to  the 
Charity  Organization  Society  in  the  knowledge  that  their 
money  is  being  expended  under  strict  medical  supervision. 

339 


Drugs. — Under  this  heading  would  be  included  the  greater 
part  of  the  treatment  ordinarily  given  to  tuberculous  patients 
in  the  dispensary.  Under  our  plan  of  management,  on  the 
contrary,  it  is  considered  of  the  least  importance  of  all,  and 
the  majority  of  our  patients  receive  no  medication  whatsoever. 
Cod-liver  oil,  to  be  sure,  is  largely  used  during  the  winter 
months,  but  is  to  be  regarded  more  as  a  valuable  form  of  food 
than  as  a  drug.  Cathartics  must  be  freely  prescribed,  as  con- 
stipation is  disastrous  during  the  process  of  overfeeding,  but 
with  this  exception,  the  exhibition  of  drugs  should  be  carefully 
restricted,  and  they  should  only  be  used  to  meet  specific  indi- 
cations, such  as  pain,  excessive  cough,  nausea,  anaemia,  etc. 
The  stomach  is  rarely  in  a  condition  to  bear  excessive  medica- 
tion, and  the  promiscuous  use  of  creosote  and  similar  prepara- 
tions is  to  be  condemned.  In  general,  less  harm  is  done  by  too 
little  medication  than  by  too  much,  and  if  we  err  at  all,  it  is 
preferable  to  do  so  upon  the  safer  side. 

Inspection  and  Regulation  of  the  Homes. — We  consider  that 
this  portion  of  our  work  is  quite  equal  in  importance  to  the 
care  of  the  patients  themselves.  Even  should  there  be  no  ap- 
parent improvement  in  the  condition  of  the  patients,  we  should 
still  maintain  that  our  efforts  would  be  well  repaid  by  the  great 
benefit  to  the  community  derived  from  this  work  in  their  homes 
alone. 

The  services  of  a  regularly  trained  nurse  are  our  mainstay 
for  this  purpose.  Each  new  case  is  referred  to  her,  with  any 
special  instructions  or  information  that  may  be  thought  advisa- 
ble, and  after  a  thorough  inspection  of  the  home  a  report  is 
made  out  by  her  upon  printed  forms  provided  for  the  purpose 
and  submitted  to  the  physician  in  charge  of  the  case,  together 
with  any  suggestions  which  may  occur  to  her  as  the  result  of 
her  visit. 

Our  general  plan  is  to  arrange  the  whole  domestic  economy 
to  the  best  interests  of  the  patient  and  to  provide  against  the 
dangers  of  infection  to  his  household  and  associates.  Careful 
and  detailed  instructions  are  given  as  to  ventilation  and  the 
principles  of  the  fresh-air  treatment,  and  practical  demonstra- 

340 


tlon  is  made  of  the  proper  method  of  disinfection  of  the  bed 
clothing,  eating  utensils,  and  personal  linen  of  the  patient ; 
also  any  necessary  suggestions  are  made  along  the  lines  of 
general  cleanliness  and  better  hygiene.  Thorough  inquiry  is 
made  concerning  the  care  which  the  patient  habitually  takes  of 
his  expectoration,  and  notice  taken  of  the  general  attitude  of 
the  whole  household  toward  the  instructions  given  at  the 
clinic.  Carelessness  is  reprimanded,  misunderstandings  cor- 
rected, and  a  cordial  spirit  of  co-operation  is  requested  and 
almost  invariably  obtained.  The  daily  habits  of  the  patient, 
the  duration  and  character  of  his  work,  his  rest,  his  exercises, 
and  his  sleep,  with  the  effects  of  each  upon  his  condition,  are 
ascertained  and  noted.  General  destitution,  as  well  as  any 
especial  need,  is  reported,  and  the  attention  of  a  suitable 
charitable  society  or  institution  is  directed  to  it.  Particular 
information  is  obtained  in  regard  to  the  patient's  diet,  his 
appetite,  and  the  nature  and  cooking  of  his  food.  Many  diges- 
tive disturbances  which  had  taxed  the  ingenuity  and  efforts  of 
the  physician,  are  often  corrected  by  a  few  practical  sugges- 
tions from  the  nurse.  Investigation  is  made  into  the  available 
facilities  for  taking  a  "rest  cure"  out-of-doors,  and  the  fire- 
escape,  the  roof,  and  the  nearest  park  are  all  considered  from 
this  point  of  view,  and  the  results  incorporated  in  the  report. 
Sometimes  the  "home  "  appears  entirely  unsuited  for  our  pur- 
pose. This  may  be  due  to  lack  of  sufificient  light  or  air,  to 
dampness  or  filth,  or  because  of  the  distance  from  the  place  of 
work.  Under  these  circumstances,  a  change  is  advised  and 
frequently  effected,  even  if  aid  from  the  Charity  Organization 
Society  or  elsewhere  is  necessary  for  the  purpose.  Other 
members  of  the  household  who  have  coughs,  or  otherwise  ex- 
cite suspicion,  are  sent  to  the  clinic  for  examination,  and  thus 
many  cases  come  under  our  treatment  much  earlier  than  would 
otherwise  have  been  the  case.  The  nurse  is  also  of  great  as- 
sistance to  the  physician  in  her  endeavors  to  explain  to  these 
patients  and  their  associates  just  how  great  and  in  what  par- 
ticulars lies  the  danger  of  infection  to  others.  The  facts  must 
be  stated  strongly  enough  really  to  frighten  them  from  care- 

341 


lessness  in  regard  to  their  expectoration,  but  it  must  be  just  as 
strongly  emphasized  that  the  freedom  frorri  danger  is  absolute 
when  proper  care  is  uniformly  exercised.  It  would  be  a  most 
unfortunate  consequence  of  our  efforts  should  our  patients  be 
shunned  as  outcasts  by  their  associates,  and  both  from  this 
misfortune,  and  from  the  dangers  of  infection,  we  hope  to  save 
them  and  their  friends,  through  their  accurate  knowledge  of 
the  subject.  By  frequent  inspections  a  general  supervision  is 
maintained  and  assurance  is  given  that  the  instructions  given 
by  the  physician  are  carefully  followed.  How  necessary  this 
is  among  the  class  of  people  with  whom  we  are  dealing  is  a 
matter  of  common  knowledge. 

This  cursory  review  of  the  part  performed  by  the  nurse  in 
our  general  scheme  needs  little  discussion  to  demonstrate  its 
value.  It  is  certainly  true  that  a  woman,  trained  in  nursing, 
who  has  the  energy,  interest,  and  ability  necessary  for  this  kind 
of  work,  can  do  much  more  than  any  physician  toward  ascer- 
taining the  exact  condition  of  affairs  and  correcting  the  evils 
existing  in  these  homes.  In  no  other  way  could  this  work  be 
at  all  complete  or  satisfactory  to  the  physician,  to  the  patient, 
or  to  the  community,  and  that  these  patients  themselves  ap- 
preciate this  fact  is  evidenced  by  the  warm  reception  given 
to  our  nurse,  as  a  friend  and  welcomie  visitor  in  their  homes. 
We,  therefore,  consider  that  she  is  an  indispensable  factor  in 
the  correct  solution  of  this  problem,  and  as  a  result  of  her 
efforts  we  can  at  least  say,  that  each  case  thus  visited  is  con- 
verted from  a  dangerous  focus  of  infection  into  a  source  of 
accurate  and  intelligent  knowledge  in  regard  to  this  disease. 

Although,  as  has  been  elsewhere  said,  the  success  of  this 
work  is  by  no  means  to  be  measured  safely  by  the  percentage 
of  cases  which  improve  or  are  actually  cured,  nevertheless  it 
may  be  of  interest  to  know  something  of  the  results  thus  far 
obtained  as  shown  by  the  condition  of  the  patients  themselves. 

During  the  months  of  January,  February,  and  March,  the 
plan  of  management  of  cases  of  pulmonary  tuberculosis  which 
has  been  above  described  was  systematically  carried  out  in  one 
of  the  medical  rooms  of  the  Vanderbilt  Clinic,  representing 

342 


one-eighth  of  the  total  number  of  patients  who  applied  for 
treatment  in  the  department  of  General  Medicine.  In  this 
room,  during  these  three  months,  there  were  forty-six  cases  of 
pulmonary  tuberculosis.  Eleven  of  the  patients  were  seen  at 
the  clinic  only  once,  and  are,  therefore,  not  included  in  this 
report.  There  remain  thirty-five  cases  in  which  we  have  had 
an  opportunity  to  judge  of  any  results  of  treatment,  and  these 
may  be  classified  according  to  the  stage  of  their  disease  into : 
early  cases,  eight;  moderately  advanced  cases,  six;  advanced 
cases,  twenty-one. 

Of  the  total  number,  twenty-two  patients  have  increased  in 
weight,  ten  have  lost  weight,  and  three  have  shown  no  change. 
The  average  increase  per  patient  in  those  who  have  gained 
weight,  is  four  pounds.  The  average  loss  per  patient  in  those 
losing  weight  is  two  and  three-quarter  pounds.  The  greatest 
gain  in  any  one  patient  is  twelve  pounds,  and  the  greatest  loss 
is  five  pounds. 

Of  the  twenty-two  patients  who  gained  in  weight,  seven 
were  early  cases,  five  were  moderately  advanced,  and  ten  were 
advanced  cases. 

Of  the  ten  who  lost  weight,  all  were  advanced  cases  and  the 
three  cases  in  which  the  weight  remained  stationary  repre- 
sented equally  the  three  stages  of  the  disease.  Expressed  in 
percentages,  we  find  improvement  in  63  per  cent  of  all  our 
cases,  in  87  per  cent  of  the  early  cases,  in  83  per  cent  of  the 
moderately  advanced  cases,  and  in  47  per  cent  of  the  advanced 
cases.  In  regard  to  the  use  of  the  body  weight  as  an  indica- 
tion of  the  progress  of  this  disease,  it  can  only  be  said  that 
this  factor  is  generally  regarded  to  be  the  best  single  criterion, 
and  that,  while  many  other  conditions  must,  of  course,  be  con- 
sidered, the  limits  of  this  report  render  their  exclusion  neces- 
sary at  this  time.  It  may  be  stated,  however,  that,  as  far  as  we 
are  able  to  judge  from  the  clinical  manifestations,  the  changes 
in  body  weight  furnish  a  very  honest  expression  of  the  general 
condition  of  these  patients. 

This  incomplete  report  does  not  attempt  to  be  in  any  degree 
conclusive,  because  of  the  small  number  of  cases  and  of  the 

343 


short  time  that  they  have  been  under  observation.  Neverthe- 
less, it  must  be  admitted  that  these  results  afford  encourage- 
ment to  us  in  the  further  prosecution  of  this  work,  and  they 
are  only  presented  here  in  order  to  demonstrate  that  our  plans 
are  not  entirely  idealistic  or  impracticable,  and  to  stimulate,  if 
possible,  a  greater  interest  in  these  cases  upon  the  part  of 
others. 

The  object  of  this  communication  has  been  accomplished  if 
it  directs  attention  from  the  physicians  active  in  dispensary 
work  to  the  problems  which  are  here  considered.  Although 
the  work  in  itself  is  comparatively  inconsiderable,  we  feel  that 
it  is  a  good  beginning  in  a  somewhat  neglected  field,  and  if  all 
the  dispensaries  in  the  city  should  be  aroused  to  a  similar  in- 
terest and  activity,  we  would  immediately  have  a  tremendous 
force  applied  to  the  solution  of  the  tuberculous  problem  and 
one  that  is  not  dependent  upon  large  public  subscriptions  for 
its  execution. 

The  writer  wishes  to  express  his  sense  of  deep  obligation  to 
Dr.  Edward  L.  Trudeau,  to  whom  is  due  his  especial  interest 
in  this  whole  subject,  and  to  Prof.  Walter  B.  James,  without 
whose  invaluable  co-operation  and  generous  support  this  par- 
ticular work  would  have  been  impossible. 


344 


Appendix  i8 

INSTITUTIONS  WHERE  TUBERCULOUS 

PATIENTS  MAY  RECEIVE  TREATMENT 

IN  NEW  YORK  AND  VICINITY 

By  CHARLES  H.  JOHNSON 


345 


INSTITUTIONS  WHERE  TUBERCULOUS  PATIENTS 

MAY  RECEIVE  TREATMENT  IN  NEW 

YORK  AND  VICINITY 

There  is  a  growing  tendency,  which  is  fast  becoming  a  rule, 
that  the  general  hospitals  of  New  York  City  will  not  receive 
patients  suffering  from  tuberculosis.  It  becomes,  therefore, 
necessary  for  those  who  desire  treatment  to  resort  to  some 
special  institution.  The  following  list  will  show  the  number 
of  such  places  where  a  tuberculous  patient  may  go,  and  it  will 
be  evident  also  that  the  number  of  institutions  to  which  a  per- 
son in  poor  circumstances,  with  perhaps  others  dependent  on 
his  exertions,  can  go  and  receive  the  necessary  treatment  at  a 
very  moderate  rate  or  free,  is  wofully  inadequate. 

Phthisis  Hospital  on  Blacktvell ' s  Island,  conducted  by  the  De- 
partment of  Charities.  This  hospital  was  opened  February  i, 
1902,  and  the  buildings  are  a  part  of  the  plant  formerly  occu- 
pied by  the  Manhattan  State  Hospital.  Several  changes  were 
made  to  make  them  meet  the  new  requirements,  and  patients 
from  Bellevue  and  Allied  Hospitals  and  other  city  institutions 
were  removed  to  it.  An  attempt  is  made  at  segregating  the 
various  stages  of  the  disease,  there  being  four  classes  and  all  in 
separate  wards.  From  the  very  start  the  applications  for  ad- 
mission have  been  numerous,  as  many  as  eleven  in  a  day  for  a 
period  of  two  weeks.  There  are  accommodations  for  190  male 
and  100  female  patients,  and  on  September  i,  1903,  the  enrol- 
ment showed  the  names  of  334  males  and  82  females.  The 
reason  for  the  lesser  number  of  female  patients  is  not  a  lack  of 
female  sufferers  from  consumption  requiring  care,  but  an  un- 
willingness on  the  part  of  women  to  go  to  the  Island. 

347 


Seton  Hospital  is  situated  on  Spuyten  Duyvil  Parkway, 
within  twenty-five  minutes'  walk  of  the  New  York  Central 
Station.  It  was  opened  in  January,  1895,  and  was  founded  by 
the  late  Sister  Mary  Irene,  one  of  the  Sisters  of  Charity.  In 
1896,  the  Board  of  Health  of  New  York  City  assumed  the  cost 
of  maintenance  in  the  hospital  of  a  large  number  of  cases  of 
pulmonary  tuberculosis,  and  this  enabled  the  institution  to  ex- 
tend its  usefulness  to  a  point  which  its  financial  condition  had 
not  hitherto  warranted,  while  it  also  resulted  in  a  change  of 
the  former  policy  of  receiving  only  curable  cases.  This 
arrangement  contined,  however,  only  for  a  brief  period,  and 
since  then  patients  have  been  accepted  as  city  charges  by  the 
Department  of  Public  Charities.  Private  patients  are  now 
rare,  as  there  is  little  accommodation  for  such  patients.  On 
September  r,  1903,  the  census  of  the  hospital  showed  188  men 
and  18  women.  The  building  stands  on  an  eminence  overlook- 
ing the  Hudson  and  contains  all  the  modern  appliances  for 
sanitation,  one  of  its  chief  attractions  being  a  large  solarium, 
filled  with  growing  plants,  where,  in  cold  or  stormy  weather, 
the  patients  delight  to  congregate.  Sister  Francis  Ignatius 
is  the  Sister  Superior.  Applications  for  the  admission  of 
free  patients  must  be  made  to  Mr.  E.  F.  Merwin,  Super- 
intendent of  Outdoor  Poor,  at  the  foot  of  East  Twenty-sixth 
Street. 

St.  Joseplis  Hospital  for  Consumptives  is  owned  and  con- 
ducted by  the  Sisters  of  St.  Francis.  It  occupies  an  entire 
block  in  the  city  of  New  York,  bounded  by  St.  Anne  and 
Brooks  Avenues  and  143d  and  144th  Streets.  It  contains  300 
beds,  nearly  all  of  which  are  entirely  free  and  constantly 
occupied  by  the  sick  poor,  who  are  admitted  irrespective  of 
creed,  race,  or  nationality.  In  winter  the  hospital  is  very 
much  crowded,  and  the  better  cases  are  sent  away  to  make 
room  for  the  weaker  ones.  It  is  always  necessary  to  put  up 
extra  beds  in  the  winter.  There  have  never  been  so  many 
cases  as  last  winter — 375 — when  two  new  rooms  had  to  be 
fitted  up  in  the  yard.  Most  of  the  patients  are  advanced 
cases,  but  patients  in  every  stage  of   the  disease  are  taken. 

348 


There  are  a  few  private  rooms  and  small  wards  where  the 
charge  is  from  $5  to  $10  per  week.  Sister  Liguori  is  the 
Sister  Superior. 

The  Lincoln  Hospital  and  Home  of  the  City  of  New  York, 
141st  Street  and  Concord  Avenue,  maintains  a  separate  build- 
ing for  free  and  pay  consumptive  patients.  Of  the  forty  beds 
available  for  consumptives  but  twenty-nine  were  occupied  on 
September  ist,  mostly  by  free  patients,  the  majority  being 
patients  received  from  the  Department  of  Charities. 

Riverside  Hospital  on  North  Brother  Island  was  used  during 
the  summer  of  1903  by  the  Department  of  Health  as  a  tuber- 
culosis hospital,  the  largest  number  cared  for  at  any  one  time 
being  eighty.  The  number  in  the  hospital  on  September  ist 
had  been  reduced  to  about  twenty,  but  the  Department  in- 
tends to  resume  the  care  of  tuberculous  patients  on  a  larger 
scale,  as  it  is  believed  that  there  is  need  for  a  hospital  where,  if 
necessary,  there  may  be  forcibly  detained  such  patients  as  ap- 
pear to  be  a  danger  to  the  community  through  refusal  to  go 
to  hospitals  or  on  account  of  persistent  neglect  in  the  neces- 
sary precautions  against  infecting  others. 

June  marked  the  beginning  of  the  third  year  of  tent  treat- 
ment of  special  classes  of  the  insane  at  Manhattan  State  Hos- 
pital East,  Ward's  Island.  On  September  ist  there  were 
eighty-seven  beds  available  for  women  and  forty-three  for 
men,  the  solarium  and  two  adjacent  wards  being  used  by  the 
women,  the  male  patients  being  cared  for  in  the  tents. 

Open-air  treatment  of  consumptives  has  of  course  been  tried 
elsewhere,  but  this  was  its  first  adoption  by  a  hospital  for  the 
insane,  and  is  said  also  to  be  the  first  instance  of  a  continuous 
system  of  tent  treatment  anywhere.  The  results  have  been  so 
encouraging  that  steps  have  been  taken  to  introduce  the  same 
system  in  other  New  York  State  hospitals,  as  well  as  in  the 
Ohio  State  Hospital  at  Columbus,  the  Protestant  Hospital 
for  the  Insane  at  Montreal,  the  Vermont  State  Hospital  at 
Waterbury,  the  Eastern  Maine  Hospital  at  Bangor,  and  else- 
where. 

The  House  of  Rest  for  Consumptives,  for  a  period  of  about 

349 


ten  years  prior  to  January,  1902,  housed  its  beneficiaries  at  St. 
Luke's  Hospital,  where  it  had  upward  of  sixty  patients  at  a 
time.  At  the  close  of  that  year  the  hospital  authorities  con- 
cluded that  they  needed  more  room,  for  their  own  use  and  de- 
cided not  to  renew  the  arrangement.  The  House  of  Rest, 
therefore,  purchased  the  Macdonough  and  Kidwell  residences 
at  Inwood,  on  Bolton  Road  between  209th  and  210th  Streets. 
When  necessary  alterations  are  made,  there  will  be  accommo- 
dations for  about  forty  patients,  although  on  the  ist  of  last 
September  there  were  but  twelve  patients  there,  owing  to  the 
fact  that  the  women's  building  was  not  then  ready  for  occu- 
pancy. Other  patients  are,  however,  supported  by  the  home 
in  various  other  places.  While  the  object  of  the  House  of 
Rest  has  been  to  be  a  refuge  for  incurable  consumptives,  it 
does  not  confine  itself  exclusively  to  the  care  of  advanced  cases. 

The  Home  for  Incurables  on  Third  Avenue  between  i8oth 
and  183d  Streets  receives  in  single  rooms  a  few  consumptives, 
most  of  whom  are  pay  patients.  Out  of  a  total  of  275  in  this 
institution  on  September  ist,  seven  were  cases  of  tuberculosis, 
and  this  is  about  the  proportion  usually  maintained. 

TJie  Brooklyn  Home  for  Consumptives,  situated  on  Kingston 
Avenue,  began  its  work  over  twenty  years  ago  and  has  not 
hesitated  to  take  in  patients  who  are  in  an  advanced  stage  of 
the  disease.  It  is  supported  by  the  different  churches  in 
Brooklyn  and  is  managed  by  a  board  of  representatives  from 
these  churches.  The  Home,  which  has  a  capacity  for  118 
patients,  had  on  the  ist  of  September  ninety-two  patients. 

Mention  of  the  excellent  work  of  the  United  Hebrew  Chari- 
ties may  not  be  out  of  order  here,  for  while  that  organization 
does  not  belong  to  the  class  of  institutions  here  enumerated, 
still  it  has  done  such  effective  work  through  its  Committee  on 
Tuberculosis  in  visiting  and  relieving  its  consumptive  poor  and 
in  persuading  many  to  make  use  of  such  hospitals  and  sanatoria 
facilities  as  are  available,  that  it  is  in  truth  one  of  the  most 
effective  institutions  in  the  city  in  the  combat  of  tuberculosis 
as  a  disease  of  the  masses.  To  quote  from  a  recent  report  of 
that  Committee: 

350 


"The  methods  made  use  of  by  the  Committee  may  be  classi- 
fied under  the  following  general  headings : 

"(A)  The  placing  of  applicants  in  charge  of  a  special  agent. 

"{B)  Careful  medical  examination  to  secure  a  correct 
diagnosis. 

"{C)  Instruction  of  consumptives  by  means  of  pamphlets, 
tracts,  etc.,  and,  in  particular,  by  verbal  guidance,  with  special 
reference  to  the  disposal  of  sputum,  cleanliness  of  person  and 
home,  proper  diet  and  exercise,  cessation  of  unhealthy  occu- 
pation, removal  to  more  sanitary  neighborhood,  and,  in  gen- 
eral, following  out  the  recommendation  of  the  Board  of  Health. 

"(Z>)  Securing  the  most  desirable  medical  treatment;  where 
possible,  in  sanatoria. 

"(u5")  Supplying  necessary  food,  such  as  eggs,  meat,  etc.,  in 
sufihcient  quantities,  and,  in  particular,  an  abundant  supply  of 
good  milk. 

"(F)  Where  change  of  climate  was  indicated  by  the  medical 
examination,  granting  transportation  to  points  desired. 

"{G)  Securing  particularly  for  the  improved  consumptive 
outdoor  work,  and,  where  possible,  positions  in  country  towns. 

"(77)   Friendly  visiting." 

Adirondack  Cottage  Sanitarium  was  opened  for  patients 
February  i,  1885.  It  is  situated  on  the  side  of  a  wooded 
mountain  near  Saranac  Lake  village,  nearly  two  thousand  feet 
above  sea  level.  It  was  the  first  institution  of  its  kind  for  the 
treatment  of  consumption  in  this  country.  It  started  on  a 
small  scale,  with  accommodations  for  only  nine  persons ;  it 
now  has  a  capacity  for  106  patients.  It  consists  of  a  main 
building  and  grouped  around  this  are  eighteen  small  cottages 
and  an  open-air  pavilion,  built  for  the  purpose  of  affording 
pleasure  and  recreation  to  the  patients  during  stormy  weather. 

The  Sanitarium  accepts  only  those  who  are  in  the  first  stages 
of  consumption  or  convalescing  from  other  pulmonary  diseases, 
or,  in  the  opinion  of  the  examining  physician,  are  likely  to  be 
benefited  by  the  Sanitarium  treatment. 

Its  purpose  is  to  offer  to  persons  in  this  condition,  who 
otherwise  could  not  afford  the  expense  of  a  stay  in  the  moun- 

351 


tains,  the  benefits  to  be  derived  from  a  change  of  climate,  a 
well-regulated  out-of-door  life  amidst  hygienic  surroundings,  a 
nourishing  diet,  and  the  latest  and  most  approved  methods  of 
medical  treatment.  The  Sanitarium  offers  such  an  opportunity 
at  a  most  moderate  cost  of  $5  a  week,  which  barely  covers  the 
necessary  expenses  for  table. 

Dr.  E.  L.  Trudeau  is  in  charge,  and  Dr.  Alfred  L.  Loomis 
of  New  York  City  is  the  examining  physician.  There  is  a  free- 
bed  fund  which  has  maintained  twenty-one  patients.  In  addi- 
tion, twenty-five  patients  have  been  supported  by  charitable 
individuals.  At  present  the  number  of  patients  is  one  hun- 
dred and  six — the  full  capacity^-with  a  waiting  list  of  from 
twenty  to  thirty. 

The  Loomis  Sanitarium,  named  for  the  founder  of  the  insti- 
tution, Dr.  Alfred  L.  Loomis,  who  died  before  the  project  was 
far  advanced,  is  situated  about  three  and  one  half  hours  from 
New  York  City.  It  is  two  and  one-half  miles  from  the  vil- 
lage of  Liberty,  in  Sullivan  County.  The  elevation  is  2300 
feet  above  the  sea  level,  the  winters  being  cold,  dry,  and  ex- 
hilarating, the  summers  cool  and  refreshing. 

The  Sanitarium  opened  in  June,  1896,  with  one  trained 
nurse,  and  before  six  months  had  passed  it  was  found  necessary 
largely  to  increase  the  force.  A  school  for  nurses  was  started 
in  1898,  and  its  pupils  have,  to  a  considerable  extent,  been 
drawn  from  the  convalescents. 

It  is  the  purpose  of  the  Sanitarium  to  admit  only  incipient 
or  moderately  advanced  cases,  and  the  basis  of  treatment  has 
been  climatic  and  hygienic.  It  was  the  first  institution  in  the 
country  to  utilize  the  X-ray  for  purposes  of  diagnosis  in  pul- 
monary diseases.  Charges  of  $12,  $15,  and  $20  per  week  are 
made.  The  Sanitarium  has  examiners  in  all  the  large  cities 
who  pass  upon  the  patients  before  they  are  accepted.  Dr. 
Henry  P.  Loomis  being  examiner  for  New  York  City. 

There  are  at  present  about  fifty  patients.  No  free  patients 
are  taken  at  Liberty.  It  is  stated  that  there  has  never  been 
any  effort  made  on  the  part  of  the  managers  of  this  institution 
to  make  any  profit  on  it,  but  everything  has  been  calculated 

353 


so  as  to  make  it  merely  self-supporting,  if  possible.  There  is 
a  charitable  annex,  which  has  now  thirty  patients  at  a  rate  of  $5 
a  week,  including  everything  except  medicines.  The  amount 
paid  for  medicines  varies  greatly  with  the  condition  of  the  in- 
dividual patient.  This  reduced  rate  does  not  cover  the  ex- 
penses of  the  annex  and  it  has  had  to  have  outside  aid  to  carry 
on  its  work.  There  are  many  more  applications  than  the  an- 
nex can  accept.  Up  to  a  recent  date  there  was  a  New  York 
branch  of  the  Loomis  Sanitarium  which  cared  for  those  who 
had  passed  the  incipient  stage  and  were  considered  among  the 
incurable.  It  did  a  very  good  work.  It  always  had  a  long 
waiting  list,  and  as  many  as  eight  have  been  refused  in  one 
week.  It  also  conducted  a  dispensary,  which  gave  much  valu- 
able and  timely  advice.  The  branch  with  the  dispensary  has 
been  discontinued,  however,  and  is,  therefore,  no  longer  avail- 
able as  a  refuge  for  this  class  of  sufferers. 

Monte fiore  Country  Sanitarium. — Memorial  Day,  1901,  was 
the  opening  day  of  the  new  building  of  this  institution.  The 
Country  Sanitarium,  however,  came  into  existence  some  years 
previous  to  that  event,  as  a  result  of  the  repeated  observations 
that  the  proportion  of  consumptives  among  the  sufferers  treated 
in  the  Montefiore  Home  for  Chronic  Invalids  was  very  large. 
In  1895,  the  project  was  started  by  Mr.  Lyman  G.  Blooming- 
dale  and  heartily  supported  by  Mr.  Jacob  H.  Schiff.  The 
Sanitarium  was  opened  in  1897  with  ten  cases  of  incipient  con- 
sumption. In  1898,  a  pavilion  was  built  for  twenty-four  addi- 
tional patients,  and  in  May,  1901,  the  present  new  buildings 
were  opened.  The  construction  of  the  buildings  was  super- 
vised by  Dr.  S.  A.  Knopf.  They  are  at  Bedford  Station, 
Westchester  County,  N.  Y.,  on  an  elevation  overlooking  a 
beautiful  valley.  There  is  a  farm  of  136  acres,  on  which  pa- 
tients do  light  outdoor  work. 

Efforts  have  been  made  to  confine  the  number  of  patients 
to  those  in  the  incipient  stages  of  the  disease,  although  no  ex- 
treme line  is  drawn.  At  the  time  of  its  dedication  this  was 
the  only  free  sanitarium  for  consumptives  in  the  United  States. 
On  September  i,  1903,  there  were  160  patients  in  the  Sani- 

353 


tarium,  with  room  for  162,  Partially  cured  patients  are  con- 
stantly being  sent  home  from  the  Sanitarium,  and  this  explains 
the  fact  that  the  institution  is  not  filled  to  its  very  limit.  At 
the  Home,  situated  on  Broadway,  138th  and  139th  Streets, 
there  is  a  special  ward  for  advanced  cases  of  tuberculosis.  At 
present  the  ward  has  twenty-eight  patients  and  a  long  waiting 
list.  The  officials  say  there  is  an  appalling  number  of  appli- 
cations for  admission  of  advanced  cases. 

Stony  Wold  Sanatorium  at  Lake  Kushaqua,  Franklin  County, 
N.Y.,  was  opened  on  August  15th  of  this  year.  It  is  primarily 
intended  for  working  girls  suffering  from  incipient  lung  trouble, 
and  is  able  to  accommodate  sixty  patients,  the  census  of  Sep- 
tember 1st  showing  twenty-three  patients  under  treatment. 

Sanatorhim  Gabriels,  belonging  to  the  Sisters  of  Mercy,  at 
Gabriels  near  Paul  Smith's  Station  in  the  Adirondacks,  receives 
incipient  cases  of  tuberculosis  and  has  accommodations  for 
about  eighty  patients  in  the  summer  and  sixty  patients  in  the 
winter. 

On  the  1st  of  September  there  were  seventy-five  patients,  of 
whom,  in  accordance  with  the  policy  of  the  hospital,  there  was 
one  free  patient  to  each  ten  patients  who  paid. 

The  Working  Girls  Vacation  Society  maintains  at  Santa 
Clara,  Franklin  County,  N.  Y.,  vacation  houses  which  are 
somewhat  on  the  order  of  sanatoria.  Admission  to  these 
houses  is  for  respectable  unmarried  working  girls  with  con- 
sumptive tendencies,  who  have  satisfactory  recommendations 
and  certificates  from  physicians  that  a  vacation  is  needed. 
The  Society  provides  a  two  weeks'  vacation  at  these  houses,  in- 
cluding railroad  fares,  at  $4  a  week ;  for  girls  who  are  unable  to 
pay  the  full  board,  the  nominal  sum  of  $1.50  per  week  is  charged. 

State  Hospital  for  the  Treatment  of  Incipient  Puhnojtary 
Tuberculosis. — This  hospital,  situated  at  Raybrook,  Franklin 
County,  about  four  miles  east  of  Saranac  Lake  in  the  Adiron- 
dacks, is  now  nearing  completion  and  will  probably  be  opened 
in  February,  1904.  It  is  intended  for  those  suffering  from  the 
first  stages  only  of  consumption,  and  while  it  will  receive  pay 
patients  when  there  is  room  for  them,  by  its  charter  it  is  com- 

354 


pelled  to  give  preference  to  the  indigent.  Medical  examiners 
for  the  Hospital  will  be  appointed  in  the  various  cities  of  the 
state,  and  only  such  persons  as  have  lived  in  the  state  at  least 
one  year  and  who  have  received  proper  certificates  from  these 
examiners  may  be  admitted. 

In  going  from  one  institution  of  this  character  to  another, 
the  same  depressing  answer  is  received  in  each  place— multi- 
tudes of  applicants  and  very  few  accommodations.  "We 
could  fill  a  thousand  rooms  if  we  had  them,"  said  a  physician 
connected  with  a  tuberculosis  sanitarium.  It  is  not  at  all  sur- 
prising that  it  is  so.  It  has  been  estimated  that,  including  the 
accommodations  which  general  hospitals,  homes,  and  sana- 
toria afford,  there  are  accommodations  for  about  one  thou- 
sand consumptives  in  the  city.  But  what  is  such  provision 
in  the  face  of  thousands  suffering  with  the  disease!  In  1902, 
over  eleven  per  cent  of  the  deaths  in  New  York  City  were 
due  to  phthisis.  There  were  7571  deaths  from  phthisis  in 
Greater  New  York  in  the  year  1902,  and  of  this  number 
4894  were  in  the  boroughs  of  Manhattan  and  the  Bronx. 
In  the  same  year  there  were  12,914  cases  of  tuberculosis 
reported,  and  9722  were  in  the  two  boroughs  mentioned 
above.  A  mere  glance  at  these  figures  reveals  the  inadequacy 
of  facilities  for  the  treatment  of  this  large  class  of  sufferers. 
The  disease  is  especially  prevalent  among  the  class  who  are  not 
able  to  lay  aside  their  business  and  go  to  mountains  or  health 
resorts.  Thousands  are  suffering  from  consumption  who  are 
compelled  to  remain  at  their  daily  work,  often,  perhaps,  a  work 
most  uncongenial  to  their  disease,  because  of  their  dependency 
upon  their  daily  wage  for  the  support  of  themselves  and  their 
families.  The  value  of  sanatorium  treatment  for  consumptives 
is  beyond  question,  and  therefore  the  necessity  of  public  sana- 
toria and  sanatoria  where  the  sick  may  be  cared  for  at  rates 
which  make  them  accessible  to  the  many  is  imperative. 


355 


Appendix  19 

SANATORIA  AND  HOSPITALS  FOR  CON- 
SUMPTIVES IN  THE  UNITED  STATES 
AND  CANADA  :  A  PARTIAL  LIST 

Collected  by  S.   A.   KNOPF,   M.D. 


357 


SANATORIA     AND     HOSPITALS     FOR    CONSUMP- 

TIVES   IN   THE    UNITED    STATES  AND 

CANADA:   A    PARTIAL    LIST 

California:  Esperanza  Sanatorium,  Altadena. 

Idylhvild  Sanatorium,  Idyllwild. 

Ballard  Pulmonary  Sanatorium,  Pasadena. 
Colorado :  National  Jewish  Hospital  for  Consumptives,  Denver. 

The  Home,  Denver. 

The  Nordrach  Ranch,  Colorado  Springs. 

Colorado  Sanatorium,  Pueblo. 

Resthaven,  Lillian   Garthwaite-Wylie  Memorial  for  Con- 
valescing Consumptives,  Sunrise  Mountain,  Morrison. 
Connecticut:  Dr.  Brooks's  Sanatorium,  New  Canaan. 
Illinois :  Cook  County  Hospital  for  Consumptives,  Dunning. 

St.  Ann  Sanatorium  for  Consumptives,  West  48th  Street, 
Chicago. 

The  Alexian    Brothers'    Hospital  —  Consumptive  Ward, 
Chicago. 

St.  Elizabeth  Hospital,  Chicago. 
Iowa :  Boulder  Lodge  Sanatorium,  Fort  Dodge. 
Louisiana:  Dr.  G.  R.  Tolson's  Private  Sanatorium,  Covington. 
Maryland:  Hospital  for  Consumptives,  Towson. 
Massachusetts:  Sharon  Sanatorium,  Sharon. 

House  of  the  Good  Samaritan,  Boston. 

Massachusetts  State  Hospital,  Rutland. 

The  Millett  Sanatorium,  East  Bridgewater. 

Channing  Home,  Boston. 

Free  Home  for  Consumptives,  Quincy  Street,  Boston. 

Cullis  Home  for  Consumptives,  Boston. 
Minnesota:  Special  Hospital  for  Tuberculous  Prisoners,  Min- 
neapolis. 
Mississippi :  Special  Hospital  for  Tuberculous  Insane,  Jackson. 
Missouri:  Mount  St.  Rose  Sanatorium,  St.  Louis. 
New  Mexico :  St.  Joseph's  Sanatorium,  Silver  City. 

General  Hospital,  Fort  Bayard. 

359 


United  States  Public  Health  and  Marine  Hospital  Service 
Sanatorium,  Capitan. 
New  York :  Adirondack  Cottage  Sanatorium,  Saranac  Lake. 

Sanatorium  Gabriels,  Paul  Smith's. 

Home  for  Consumptives,  Brooklyn. 

The  Loomis  Sanatorium,  Liberty. 

Manhattan  State  Hospital  East,  Ward's  Island. 

Montefiore  Home  Country  Sanitarium,  Bedford  Station. 

St.  Joseph's  Hospital  for  Consumptives,  New  York  City. 

Seton  Hospital,  Spuyten  Duyvil. 

Tuberculosis  Infirmary,  Blackwell's  Island. 

Riverside  Sanatorium,  North  Brother  Island. 

Stony    Wold     Sanatorium,     Lake     Kushaqua,    Franklin 
County. 

Clinton  Prison,  Dannemora.     Separate  building  for  tuber- 
culous prisoners. 

House  of  Rest  for  Consumptives,  Bolton  Road  and  209th 
Street. 

Montefiore  Home,  Broadway  and  138th  Street. 

Home  for  Incurables,  Third  Avenue  and  i8oth  Street. 

Kings  County  Hospital  Infirmary. 

Hill   Crest,    Santa   Clara,    Franklin    County.      (Summer 
months  only.) 

The  Edgemont,  Liberty.    • 

Tent  Colony  of  Dr.  Stubbert,  Liberty. 

Prescott  Reception  Cottage,  Saranac  Lake. 
North  Carolina:  Pineshire  Sanitarium,  Southern  Pines. 

Winyah  Sanitarium,  Asheville. 

St.  Joseph's  Retreat,  Asheville. 
North  Dakota :  Oak  Park  Sanatorium  for  Consumptives,  Minot. 
Ohio :  Municipal  Tuberculosis  Sanatorium,  Cleveland. 

Cincinnati  Branch  Hospital  for  Consumptives,  Cincinnati. 
Pennsylvania:  Free  Hospital  for  Poor  Consumptives,  White 
Haven. 

Home  for  Consumptives,  Philadelphia. 

Scranton  Sanatorium,  Scranton. 

Rush  Hospital,  Philadelphia. 

360 


Chestnut  Hill  Hospital,  Philadelphia. 

Nott  Home  of  Jewish  Hospital,  Philadelphia. 
Texas :  Camp  Reliance,  Comfort. 

Dr.  L.  W.  Cook's  Sanatorium,  Boerne. 
Canada:  Free  Home  for  Consumptives,  Gravenhurst,  Ontario. 

Muskoka  Cottage  Sanatorium,  Gravenhurst,  Ontario. 

Montreal  Sanatorium  for  Consumptives,  Montreal,  Quebec. 

This  list,  incomplete  though  it  may  be,  is  inserted  because 
the  mere  names  and  addresses  may  prove  of  use.  A  directory 
aiming  to  give  a  comprehensive  view  of  all  the  work  being  done 
in  the  United  States  and  Canada  for  the  relief  and  prevention 
of  tuberculosis  is  in  preparation  by  this  Committee. 


361 


Appendix  20 

A  BRIEF  LIST  OF  IMPORTANT  WORKS 
IN  REGARD  TO  TUBERCULOSIS 

Selected  by  S.  A.  KNOPF,  M.D. 


363 


A  BRIEF  LIST  OF  IMPORTANT  WORKS  IN 
REGARD  TO  TUBERCULOSIS 

ENGLISH 

Brush,  E.  F.,  Human  and  Bovine  Tuberculosis. 

Buckley,  J.  M.,  A  Hereditary  Consumptive's  Successful  Battle  for 

Life. 
Campbell,    Harry,    Respiratory   Exercises   in   the   Treatment  of 

Disease. 
Chapin,  Chas.  V.,  Municipal  Sanitation  in  the  United  States. 
Checkley,  Edwin,  A  Natural  Method  of  Physical  Training. 
Ciccolina,  S.  M.  A,,  Deep  Breathing. 
Davis,  N.  S.,  Jr.,   Consumption,  How  to  Prevent  it  and  How  to 

Live  with  it. 
Delafield  and  Stillman,  A  Manual  of  Physical  Diagnosis. 
Denison,  Charles,  Climates  of  the  United  States. 
Denison,  Charles,  Exercise  and  Food  for  Pulmonary  Invalids. 
Densmore,  Emmett,  Consumption  and  Chronic  Diseases. 
Densmore,  Helen,  How  Nature  Cures. 
Evans,  Geo.  A.,  Historical  and  Geographical  Phthisiology. 
Flick,  Lawrence  F.,  Consumption,  Preventable  and  Curable. 
Funk  &  Wagnalls  Co.,  The  Prevention  of  Disease.      Vols.   I. 

and  II. 
Goodwin,   Chas.    H.,   Treatment  of  Diseases  of  the   Heart   and 

Lungs. 
Hayes,   J.    R.,   How  to  Live  Longer  and  Why  we   do   not   Live 

Longer. 
Hillier,  Alfred,  Tuberculosis:   Its  Nature,  Prevention,  and  Treat- 
ment. 
Hunter,  Robert,  Tenement  Conditions  in  Chicago. 

365 


Knopf,  S.  A.,  Pulmonary  Tuberculosis:  Its  Modern  Prophylaxis 
and  the  Treatment  in  Special  Institutions  and  at  Home. 

Knopf,  S.  A.,  Tuberculosis  as  a  Disease  of  the  Masses  and  How  to 
Combat  it. 

Knopf,  S.  A.,  Tuberculosis:  Diagnosis,  Prognosis,  Prophylaxis, 
and  Treatment  (Twentieth  Century  Practice  of  Medicine,  Vols. 
XX.  and  XXI.). 

Lake,  Richard,  Laryngeal  Phthisis. 

Latham,  Arthur,  Diagnosis  and  Modern  Treatment  of  Pulmonary 
Consumption. 

Loomis,  Alfred  L.,  Physical  Diagnosis. 

Lucas,  Joseph  J.  S.,  Nordrach  at  Home. 

McCoy,  John,  Consumption,  How  to  Prevent  it  and  How  to  Cure 
it. 

Mays,  Thomas  J.,  Consumption,  Pneumonia,  and  their  Allies. 

Mays,  Thomas  J.,  Pulmonary  Consumption,  a  Nervous  Disease. 

New  York  City  Board  of  Health,  Report  to  Mayor  Strong  in 
Relation  to  Pulmonary  Tuberculosis,  1897. 

Paget,  Stephen,  Surgery  of  the  Chest. 

Philip,  R.  W.,  Pulmonary  Tuberculosis. 

Philip,  R.  W.,  A  Thousand  Cases  of  Pulmonary  Tuberculosis. 

Reinhardt,  Ch.,  and  Thomson,  David,  Open-air  Treatment 
and  Life  in  an  Open-air  Sanatorium. 

Solly,  S.  E.,  Medical  Climatology. 

Squire,  J.  Edward,  The  Hygienic  Prevention  of  Consumption. 

Steell,  Graham,  The  Physical  Signs  of  Pulmonary  Disease. 

Tussey,  A.  Edgar,  High  Altitudes  for  Consumptives. 

Tyson,  James,  Physical  Diagnosis. 

Walters,  F.  R.,  Sanatoria  for  Consumptives. 

Weber,  Hermann,  Chronic  Pulmonary  Phthisis. 

Wide,  Anders,  Handbook  of  Medical  and  Orthopedic  Gymnastics. 

Williams,  F.  H.,  The  Roentgen  Rays  in  Medicine  and  Surgery. 

Ziemssen,  H.  von,  Pulmonary  Tuberculosis:  Its  Etiology,  Symp- 
tomatology and  Therapeutics. 

PERIODICALS 

The  British  Sanatoria  Annual^  London,  1901. 

Transactions  of  the  British  Congress  on  Tuberculosis^  vols,  i.,  ii.,  iii., 
and  iv. 

366 


The  Canada  Lancet,  Tuberculosis  Number,  December,  1901. 
American  Congress  of  Tuberculosis  Bulletin,  vol.  i.,  part  i.,  1900. 
The  y^ournal  of  Tuberculosis,  Asheville,  N.  C. 

Tuberculosis,   Journal  of  National    Association    for    Prevention    of 
Consumption,  London,  England. 


FRENCH 

Artault  de  Vevey,  S.,  Tuberculosa  et  Injections  Huileuses. 

Barbier,  Henry,  Semiologie  Pratique  des  Poumons.  • 

Barety,  A.,  Du  Climat  de  Nice. 

Barth,  H.,  Therapeutique  de  la  Tuberculosa. 

Beaulavon,  Paul,  La  Phthisie:   Hygiene— Cure — Guerison. 

Beaulavon,    Paul,    La  Tuberculose    Pulmonaire  dans  les   Sana- 
toria. 

Bernardeau,  E.,  Histoire  de  la  Phthisie  Pulmonaire. 

Bouloumie,  P.,  Les  Maladies  Evitables. 

Brouardel,    P.,    La   Propagation    de   la   Tuberculose.      (Rapport 
Gouvernemental),  1900. 

Brunet,  Felix,  Le  Sue  Pulmonaire. 

Chauvain,  L.,   Pour  se  Defendre  contre  la  Tuberculose   Pulmo- 
naire. 

Chuquet,  A.,  L' Hygiene  des  Tuberculeux. 

Comte  de  Goyan,  Des  Indications   Therapeutiques  du   Regime 
Lacte. 

Congr^s  de  la  Tuberculose,  1898. 

Daremberg,  G.,  Traitement  de  la  Phthisie  Pulmonaire.     Vols.  I. 
and  II. 

De  La  Harpe,  Formulaire  des  Stations  d'Hiver,  etc. 

Grancher,  J.,  Maladies  de  I'Appareil  Respiratoire. 

Grillot,  Henry,  Le  Sanatorium  Frangais. 

Hameau,  G.,  Le  Climat  d'Arcachon  et  le  Sanatorium. 

Herard,  Cornil  et  Hanot,  La  Phthisie  Pulmonaire. 

Jaccoud,  S.,  Phthisie  Pulmonaire. 

Jourdin  et  Fischer,   Le  Diagnostic  Precoce    de   la  Tuberculose 
Pulmonaire. 

Knopf,   S.  A,,    Les   Sanatoria,    Traitement  et   Prophylaxie  de  la 
Tuberculose  Pulmonaire. 

367 


Knopf,    S.    A.,    La   Tuberculose   Consideree   comme   Maladie   du 

Peuple,  des  Moyens  de  la  Combattre. 
Kliss,    Georges,    De    I'Heredite    Parasitaire    de    la    Tuberculose 

Humaine. 
Lalesque,  F.,  Cure  Marine  de  la  Phthisic  Pulmonaire. 
Leroux,  Charles,  Les  Hopitaux  Marins. 

Letulle,  M.,  La  Croisade  centre  la  Tuberculose  (Presse  Medicale). 
Letulle,  M.,  Le  Sanatorium  Populaire  Ideal. 

Petit,  E.  P.  Leon,  Le  Phthisique  et  son  Traitement  Hygienique. 
Pujade,  P.,  La  Cure  Pratique  de  la  Tuberculose. 
Ribard,  Elisee,  La  Tuberculose  est  Curable. 
Sabourin,  Ch.,  Traitement  Rationnel  de  la  Phthisie. 
Santa,  Pietra,  Traitement  Rationnel  de  la  Phthisie  Pulmonaire. 
Sersiron,  G.,  Les  Phthisiques  Adultes  et  Pauvres. 
Straus,  L.,  La  Tuberculose  et  son  Bacille. 
Teissier,  Pierre,   Des  Lesions  de  I'Endocarde  chez  les  Tuber- 

culeux. 
Thiery,  Paul,  De  la  Tuberculose  Chirurgicale. 
Triboulet  et  Mathieu,  L'Alcool  et  I'Alcoohsme. 
Weber,  Hermann,  Climatotherapie. 


PERIODICALS 


La  Lutte  Atitituberculeuse. 
La  Tuberadose  Lnfantile. 
Revue  de  la   Tuberculose. 


GERMAN 


Besold,  Gustav,   Die    Anstaltsbehandlung   der  Tuberkulose  der 
Atmungswege. 

Brehmer,  Hermann,  Dr.  Brehmer's  Heilanstalt  fiir  Lungenkranke 
(1889). 

Cornet,  G.,  Die  Tuberkulose. 

Dettweiler,  P.,  Die  Behandlung  der  Lungenschwindsucht  in  ge- 
schlossenen  Heilanstalten. 

FlUgge,  C,  Dr.  Brehmer's  Heilanstalt  fiir  Lungenkranke  (1890). 

Groningen,  G.  H.,  Wie  wird  man  Tuberkulos? 

Hohe,  Adolf,  Die  Bekampfung  und  Heilung  der  Lungenschwind- 
sucht. 

368 


Jacob  (Paul)  and  Pannwitz  (G.),  Entstehung  und  Bekampfung 

der  Lungen-Tuberkulose.      Bande  I.  und  II. 
Knopf,  S.  A.,  Die  Tuberkulose  als  Volkskrankheit  und  deren  Be- 
kampfung. 
Leyden,  E.  von,   Handbuch  der  Ernahrungstherapie.     Bande  I. 

und  II. 
Leyden,  E.  von,  Internationale  Beitrage   zur  Inneren   Medicin. 

Festschrift. 
Pannwitz,   G.,   Bericht  iiber  den  Congress  der  Bekampfung  der 

Tuberkulose  als  Volkskrankheit.      Berlin,  1899. 
Pannwitz,  G.,  Deutsche  Industrie  und  Technik  bei  Einrichtung 

von  Sanatorien  und  Krankenhausern. 
Petzold  und  Stintzing,  Handbuch  der  Therapie  innerer  Krank- 

heiten.     Band  III. 
Predbhl,  A.,  Die  Geschichte  der  Tuberkulose. 
Schilling,  Friedrich,  Diatotherapie. 

Turban,  K.,  Beitrage  zur  Kenntniss  der  Lungentuberkulose. 
Weicker,  Hans,  Tuberkulose — Heilstatten — Dauererfolge. 
Wolff,  Felix,  Moderne  Behandlung  der  Lungenschwindsucht. 

PERIODICALS 

Tuberculosis,  in  English,  French,  and  German,  Leipzig. 
Zeitschrift  fur  Didtetische  u.  Physikalische  Therapie. 
Zeitschrift  fiir  Tuberkulose  u.   Heilsidttenwesen. 

OTHER  LANGUAGES 

Bluntenthal,  Ph.,  Tuberculosis.      (Russian.) 
Ferreira,  ClementO,  Tuberculose  e  Sanatorios.     (Portuguese.) 
Knopf,  S.  A.,  Translations  of  Preisschrift  into  Bulgarian,  Dutch, 
Hebrew  (Yiddish),  Hungarian,   Icelandic,  Italian,  Polish,  Por- 
tuguese, Russian,  Spanish. 


369 


INDEX 


Adirondack  Cottage  Sanitarium  ....... 

Age: 

at  death,  Average  ........ 

of  patients  in  the  Tuberculosis  Infirmary,  Blackwell's  Island 
Variations  of  death-rate  from  tuberculosis  according  to 

Agricultural  colonies  for  convalescent  consumptives     . 

Air-shafts  in  New  York  tenements       ...... 

Alcohol,  Recovery  from  tuberculosis  prevented  or  retarded  by     . 

Alcoholism  : 

Influence  on  the  death-rate  from  consumption 
Predisposition  to  tuberculosis  due  to     ....         . 

Aldermen  of  New  York  City,  Board  of,  Resolutions  in  regard  to  a 
municipal  sanatorium         ....... 

Alexian  Brothers'  Hospital,  Chicago,  Illinois       .... 

Altitude  in  the  treatment  of  consumption     ..... 

Amusement,  see  Recreation. 

Annals  of  the  American  Academy  of  Political  and  Social  Science 

Attendance  at  lectures  ........ 

Aggregate     .......... 


PAGE 
236,    351.    360 


41 

128 

37-42 

24,    203 

•  317 

189,    232,    307 

.     47.  53.  61 
79,  188,  310 


15.  293 

.       359 

230,  231,  295 

vi. 

137-142 

9 


Bacillus  tuberculosis    ..... 

Action  in  the  body        .... 

Conditions  necessary  for  multiplication 
Defenses  of  the  body  against 
Description  ...... 

Discovery,  by  Robert  Koch . 
Duration  of  life    ..... 

Effect  of  cold,  heat,  and  disinfectants  on 
in  dust  ...... 

in  the  laboratory 

in  meat  and  milk  .... 

in  tuberculous  tissues   .... 
Method  of  extermination 
Modes  of  entrance  into  the  body 

371 


143-149,  157, 

146,  147, 

145, 


165,  174 

158,  247 

159,  246 
149,  250 
145,  246 
145,  156 
145,  159 
145,  247 

145-148,  159,  175,  248 

146 

146,  148,  164 

146 

112 

148,  174,  213,  247 


139-  I40, 


14, 


13, 


Bacteria,  Diseases  caused  by         ....         . 

Baird,  Addison  W.,  M.D 

Ballard  Pulmonary  Sanatorium,  Pasadena,  California 
Belle vue  and  Allied  Hospitals,  New  York  City   . 

Berkeley,  W.  N.,  M.D 

Bibliography  on  the  subject  of  tuberculosis 

Biggs,  Hermann  M.,  M.D.,  iii.,  3,  9,  10,  97,  9S,  100,  108,  137,  13S.  269 

Tuberculosis — Its  Causation  and  Prevention         .... 
Blackwell's  Island,  New  York,  see  Tuberculosis  Infirmary. 
Board  of  Aldermen,  see  Aldermen. 
Board  of  Estimate  and  Apportionment  of  New  York  City,  Report 

to,  in  regard  to  a  municipal  sanatorium     ..... 
Board  of  Health  of  New  York  City,  see  Department  of  Health. 
Boards  of  Health,  Functions  in  suppressing  tuberculosis 

Bodington,  George,  M.D 

Bohemians  in  the  United  States,  Consumption  among 
Bone,  Tuberculosis  of  the  ...... 

Boulder  Lodge  Sanatorium,  Fort  Dodge,  Iowa   . 
Brandt,  Lilian 

The  Social  Aspects  of  Tuberculosis 
Brehmer,  Dr.      ........ 

Brooks,  Dr.,  Sanatorium  of.  New  Canaan,  Connecticut 

Brooks,  Harlow,  M.D. 

Brouardel,  Prof.  ....... 


iii.,  8, 


PACK 
141,    142 

.  359 
301,  302 

137,  138 

365-369 
308, 328 
153-169 


293-302 

274 

233 

54 

208 

359 
10,  141 

31-115 

.  233 
.  359 
.  138 
.       114 


California: 

Consumption  in    ........         . 

Sanatoria  for  consumptives  ....... 

Camp  Reliance,  Comfort,  Texas  ...... 

Canada,  Sanatoria  for  consumptives  in         ....         . 

Canadians  in  the  United  States,  Consumption  among 

Casimir-Perier,  M.       . 

Cattle,  Tuberculosis  in         .         .         .         .         .         .98,  146,  157, 

Cause  of  death.  Inaccurate  reporting  of        ....         . 

Causes  of  consumption,  see  Tuberculosis. 

Central  International  Tuberculosis  Committee    .         .         . 

Channing  Home,  Boston,  Massachusetts     ..... 

Charities     ........... 

Charity  Organization  Society  of  New  York,  iii.,  v.,  3,  7,  12,  15,  17, 

196,  227,  274, 
Chestnut  Hill  Hospital,  Philadelphia,  Pennsylvania    . 
Children,  Tuberculosis  among    .         .         ,         .         .         .  41, 

Chinatown,  New  York  City,  Consumption  in       ...         . 

Chinese  in  the  United  States,  Consumption  among 

372 


80,  83 

.       359 

361 

.       361 

.  60-62 

114 

165,  203,  247 

33 

.       114 

.       359 

vi. 

109,  126,  127 

297,  339.  341 

361 

192,  207-224 

.    88,  89,  91 

49,  60 


PASB 

Cincinnati  Branch  Hospital  for  Consumptives,  Cincinnati,  Ohio  .         .       360 

Circular  :  Information  for  consumptives  and  those  living  with 

them 10,  267-269 

Circulars  distributed  by  the  New  York  City  Department  of  Health     .         .         98 
Cities  : 

Consumption  in    .         .         .         .         .         .         .         •    5i.  53-  54.  60.  74.  75 

Improvement  in  healthfulness       .         .         .         .         .         .         .         .154 

Clergymen,  Duties  of,  in  the  combat  of  tuberculosis    .....       193 

Climate  : 

in  the  treatment  of  tuberculosis 191,  228,  338 

Relation  to  the  prevalence  of  consumption    .....  80,  81 

The  most  desirable,  for  consumptives  .......       230 

Climatic  a?tcl  Sanatorium  Treatment  of  Consumptives,  by  Henry 

P.  Loomis,  M.D 227-239 

Clinton  Prison,   Dannemora,   New  York,  Building  for  tubercu- 
lous prisoners    ...........       360 

Colonies  for  consumptives,  Agricultural       ......  24,  203 

Colorado  : 

Consumption  in    .  .  .  .  .  .  .  .  .  .  .         83 

Sanatoria  for  consumptives  .........       359 

Colorado  Sanatorium,  Pueblo,  Colorado      .......       359 

Colored  population  of  the  United  States.  High  death-rates  among       .  .  48-52 

Committee  on  the  Prevention  of  Tuberculosis  of  the  Charity  Or- 
ganization Society  of  New  York        .        iii.,  v.,  vi.,  126,  127,  227,  297,  339 
Appeals  for  funds  : 

September,  1902    ..........  7 

September,  1903    ..........         22 

Appointed  by  the  Charity  Organization  Society    .....  3 

Contributions,  July,  1902-June,  1903  : 

for  general  work    ..........  25-27 

for  relief  work        ..........         27 

Correspondence  with  the  Governor  of  New  York  : 

in  regard  to  the  Goodsell-Bedell  bill 15-20 

in  regard  to  the  State   Hospital  for  Incipient  Cases  of 

Tuberculosis  ..........         14 

Dispensaries,  Work  in  regard  to  .         .         .         .         .         .         .         .  13,  14 

Educational  work         ..........     9-13 

Financial  report  for  year  ending  June  30,  1903     .....  25-27 

Hospital    and   sanatorium    provision  for  consumptives. 

Work  in  relation  to    ........  .   14-20 

Lectures  .         .         .         .         .         .         ,         .         .         .         .    9,  10 

Courses  given         ..........  9 

List 137-142 

Literature  distributed  ..........  10-12 

Membership  .         .         .         .         .         .         .         ."        .      '  .         .   iii.,  3 

373 


PAGE 

Committee  on  the  Prevention  of  Tuberculosis — Continued. 

Methods  of  work  .         .  ........        v. ,  7-24 

Origin .         .      3,  6 

Plans : 

for  year  1902-3 4 

for  year  1903-4     . 22 

Publications .         .         8,  10,  1 1,  12 

Relief  work  .         .         .         .         .         .         .         .         .         .  20,  21 

Remedial  and  preventive  measures       .         .         .         .         .         .,        .  13-22 

Research  work  carried  on  ........  8 

Resolutions  framed  : 

in  regard  to  patent  medicines         .         .         .         .         .         .         ,         12 

in  regard  to  proposed  changes  in  the  Tenement  House 

Law        ......'.....         21 

Review  of  the  first  year :  igo2-j  .........     3—27 

Schedule   for   recording   the    social   history   of   cases   of 

consumption  ..........  8 

Scope  and  purpose        .         .         .         .         .         .         .         .         .         .     v.,  4 

Social  aspects  of  tuberculosis,  Research  in    .         .         .         .         .         .  8 

Staff 4 

Communicable  and  contagious,  Distinction  between    .....       160 

Connecticut,  Sanatoria  for  consumptives      .         .         .         .         .         .         .       359 

Consumption,  see  Tuberculosis,  Pulmonary. 

Germs  of,  see  Bacillus  tuberculosis. 
Consumptives  : 

Complete  isolation  impracticable  and  unnecessary         ...  5,  257 

Duties  to  themselves  and  to  the  community  ....         175-191 

Duty  of  the  community  in  regard  to      .         .         .         .         .  v.,  igi-204 

Expenditure  for  the  care  of,  in  New  York  City  institutions  .         .         .       167 
Homeless,  in  New  York  City        ........       200 

in  New  York  tenements        .......         167,  305-330 

in  the  Tuberculosis  Infirmary,  Previous  conditions  of  life     .         .         128-133 
Industrial  decline  .........  65,  130 

Information  for,  and  those  living  with  them  ....        267-269 

not  necessarily  a  danger  to  the  public  .         .         .         .         .         .     v.,  5,  162 

Number  in  New  York  City 167 

Provision  for  : 

Inadequacy,  v.,  13,  167,  168,  199,  200,  235,  258,  274,  293.  322,  335,  355 

in  and  near  New  York  City 167,  347-355 

Cook,  L.  W.,  M.D.,  Sanatorium  of,  Boerne,  Texas    .....       361 

Cook  County  Hospital  for  Consumptives,  Dunning,  Illinois         .         .         .       359 
Cost  of  tuberculosis     .........         108,  165,  166 

Cox,  Charles  F.,  Chairman  of  the  Committee  on  the  Prevention 

of  Tuberculosis  .         .         .         .         .         .         .         .         .         .        iii. 

Creighton,  Sarah  R.,  M.D 138,  141 

374 


Cullis  Home  for  Consumptives,  Boston,  Massachusetts 
"  Cures"  for  consumption,  see  Patent  medicines. 

Daniell,  Annie  S.,  M.D 

Dark  rooms  in  New  York  City 

Death-rate,  General  ...... 

Decrease       ........ 


PAGE 

359 


138,  141 

202,  221,  317 

.     36,  46,  48 

93.  154 


Significance,  when  high        .         .         .         .         .         .         .         .         .153 

Death-rate  from  all  tubercular  diseases        .         .         .         .         .         .         .  38,  39 

Decrease 99,  156 

Death-rate  from  consumption  : 

Decrease 92-107,  156,  165,  167,  168,  233,  308 

according  to  age  and  sex        .......         105-107 

compared  with  decrease  in  general  death-rate         ....         93 

in  cities,  compared  with  rural  districts  .....  94,  95 

in  New  York  City,  compared  with  the  United  States     .         .  95-102 

in  the  registration  area  of  the  United  States  ....         92 

in  the  wards  of  Manhattan    .......         102-104 

Significance 93.  95.  104,  107 

Increase,  in  two  wards  of  Manhattan  ......       102 

Sources  of  error  in        ..........         34 

Variations,  according  to 

age 37-42 

color      ............  48-52 

density 74-78 

marital  condition  .........  43-47 

nationality 53-57 

number  of  persons  to  a  room,  in  London  .....  77 
number  of  rooms  to  an  apartment,  in  Dundee  ....  78 
occupation     ...........  62-74 

sex .         36 

size  of  cities,  in  France  ........         74 

in  the  United  States       ........         75 

wards,  in  Manhattan     . 85-88 

Decrease  in  prevalence  of  tuberculosis,   see  Death-rate  from  con- 
sumption. 

Dembo,  Fanny,  M.D. 139 

Density  of  population  : 

Influence  on  prevalence  of  consumption  in  Manhattan  ob- 
scured by  other  factors  .         .         .         .         .         .         .         .  86-88 

Variations  of  death-rate  from  consumption  according  to        .         .         .  74-78 

Department  of  Health,  New  York  City 3,  10,  15,  267 

Registration  of  cases  of  pulmonary  tuberculosis  ....  88,  98,  167 
Summer  Corps  of  Physicians,  for  visiting  tenements  ....  97 
System  for  the  control  of  tuberculosis 97-101,167 

375 


PAGE 

Department  of  Public  Charities,  New  York  City  .     3,  123,  126,  127,  291,  293 

Dependence  caused  by  tuberculosis,  Illustrations  of   ....         109-111 

Devine,  Edward  T.    .........         .     iii.^  15-20 

Diagrams,  see  Statistics. 

Diet  in  the  treatment  of  tuberculosis  ....         191.  235,  299,  339 

Directory  of  work  for  the  relief  and  prevention  of  tuberculosis, 

in  preparation  ..........       361 

Disease,  Advance  in  the  control  of      ,         .         .         .         .         .         -155,  156 

Disinfection  of  apartments  occupied  by  consumptives  .         .         .  98,  257 

Dispensaries        .         .         .         .         .         .         .         .         .         .         .   13,  23,  328 

Bellevue  and  Allied  Hospitals,  Special  classes  proposed        ...  14 

Management  of  cases  of  pulmonary  tuberculosis  ,         .  13,  333-344 

Mount  Sinai  Hospital  .........         14 

Municipal    .         .         .         . 13,  24,  201 

New  York  Nose  and  Throat  Hospital  ......         13 

Possibilities,  in  the  combat  of  tuberculosis  ....  13,  333 

Post-Graduate  Hospital,  Dr.  Russell's  class  ....  13,  334 

Provision  in  New  York  City         .......  13,  334 

St.  Bartholomew's  Clinic      .........         13 

Vanderbilt  Clinic  .         .         .         .         .         .         .         .         .         .         13 

Description  of  system    ........         336-342 

Results  obtained  ........        342,  343 

Dissipation,  Effect  on  susceptibility  to  consumption    .         ...         .         .         79 

Dow,  E.  L.,  M.D 137,  138,  141 

Drink,  Habits  of  patients  in  Tuberculosis  Infirmary  in  regard  to  .         .       132 

See  also  Alcohol. 
Drop  infection    ............       175 

Drugs  in  the  treatment  of  tuberculosis         .......       340 

Dust,  Tubercle  bacilli  in     .....         .  145-148,  159,  175,  248 

Duties  of  the  Individual  and  the  Government  in  the  Combat  of 

Tuber ctilosis,  by  S.  A.  Knopf,  M.D.         ....  10,  173-201 


Easton,  Christopher    ......... 

Edgemont,  The,  Liberty,  New  York  ..... 

Education  of  the  public.  Value  of        ....         .  168, 

Educational  propaganda  of  the  Committee  .... 

Educational  value  of  work  of  the  New  York  Health  Department 

Employers,  Duties  of,  in  the  combat  of  tuberculosis 

England,  Sanatoria  in         .......         . 

Esperanza  Sanatorium,  Altadena,  California        .         . 
Expectation  of  life,  Increase  in  ...... 

Expectoration,  New  York  City  ordinance  against 
See  also  Sputum. 


.   125 

360 

3,  256,  257 

9-13,  274 

lOI 


.   233 

.   359 

154,  155 

100 


Fear  of  contact  with  consumptives  unwarranted  .....       162 

376 


PAGE 

Federal  government,  Duties  of,  in  the  combat  of  tuberculosis      .         203,  204,  256 

Financial  report  of  the  Committee 25-27 

Fishberg,  M.,  M.D I37,  138 

Folks,  Homer iii.,  3,  8 

Report  to  the  Board  of  Estimate  a}td  Apportionment  m  regard 

to  a  municipal  sanatorium      .         .         .         .         .         .  15,  293-302 

Some  Social  Aspects  of  the  Tuberculosis  Infirmary  on  Black- 
well's  Island 9,  125-133 

Fratice,  Sanitary  Federation  projected 114 

Free  Home  for  Consumptives,  Boston,  Massachusetts         ....       359 
Free  Home  for  Consumptives,  Gravenhurst,  Ontario  ....       361 

Free  Hospital  for  Poor  Consumptives,  White  Haven,   Pennsyl- 
vania        ............       360 

Freeman,  R.  G.,  M.D 137,  139,  141 

Fresh  air.  Importance  of     .         .     12,  113,  147,  197,  198,  220-223,  251,  252,  264, 

268,  327,  338 

Gabriels  Sanatorium,  Paul  Smith's,  New  York    .....       354,  360 

General  Hospital,  Fort  Bayard,  New  Mexico      .         .         .         .         .         .       359 

Germans  in  the  United  States,  Consumption  among   .....         60 

Germany  : 

Compulsory  insurance  .........       322 

Sanatoria     .........         232,  233,  235,  322 

Germs  of  Consuntption,  by  J.  H.  Huddleston,  M.D.  .         .         .         145-149 

See  also  Bacillus  tuberculosis. 

Girsdansky,  Max,  M.D 138,  142 

Goodsell-Bedell  bill : 

Protest  against,  by  the  Committee        .......         16 

Public  hearing  requested      .         .         .         .         .         .         .         .         .         18 

Significance  ..........         20,  296 

Text 16 

Gorbersdorf,  Germany,  Sanatorium  in         .......       233 

Habits  and  social  customs,  Influence  on  the  prevalence  of  con- 
sumption ...........         79 

Handbook  on  the  Prevention  of  Tuberculosis,  Object  of    ...         .  v 

Harper's  Monthly       ■         .         .         .         .         .         .         .         .         .         vi.,  241 

Hebrews,  Consumption  among    ......    55,  56,  61,  86,  88,  91 

Hill  Crest,  Santa  Clara,  New  York 354,  360 

Hoffman,  Frederick  L.        ..........         70 

Home,  The,  Denver,  Colorado  .         .         .         .         .         .         .         .       359 

Home  for  Consumptives,  Brooklyn,  New  York  ...         .         .        350,  360 

Home  for  Consumptives,  Philadelphia,  Pennsylvania  ....       360 

Home  for  Incurables,  New  York  City 350,360 

Horticultural  colonies  for  convalescent  consumptives  ...         .         .         .         24 

Hospital  for  Consumptives,  Towson,  Maryland  ......       359 

377 


PAGE 

Hospital  for  Tuberculous  Insane,  Jackson,  Mississippi  ....  359 
Hospital  for  Tuberculous  Prisoners,  Minneapolis,  Minnesota  .  .  .  359 
Hospital  provision  for  consumptives  in  New  York      .  167,  199,  258,  349-355 

House  infection  .........  91,  163,  253 

Causes .         317-321 

Examples 92,  313-317 

Significance,  in  New  York  .........         92 

House  of  Rest  for  Consumptives,  New  York  City        ....        349,  360 

House  of  the  Good  Samaritan,  Boston,  Massachusetts  ....       359 

Housing  conditions.  Relation  to  death-rate  from  consumption    .  88,  102,  305-330 

See  also  Tenements. 
Howells  and  Stokes,  Plans  for  a  Municipal  Sanatorium       .         .         .         287-290 

Huber,  J.  B.,  M.D 138,  139,  140,  141 

Huddleston,  J.  H.,  M.D. iii.,  137 

Germs  of  Consumption  ........    9,  145-149 

Hungarians  in  the  United  States,  Consumption  among        .         .         .  55,  102 

Idyllwild  Sanatorium,  Idyllwild,  California         ......       359 

Illinois,  Sanatoria  for  consumptives    .......        234,  359 

Immigrants,  Exclusion  of  consumptive        .......  5 

Immigration,  Influence  on  the  death-rate  from  consumption  in 

New  York  City .         .       loi 

Indians,  Consumption  among      .........         50 

Industrial  decline  caused  by  consumption    ......  65,  130 

Infection  : 

by  ingestion 148,  164,  175,  184,  247 

by  inhalation 148,  159,  164,  174 

by  inoculation 148,  164,  175,  185 

by  transmission  through  direct  contact  .....        163,  175 

from  sweat-shop  work  .........       308 

of  apartments,  houses,  and  institutions  .      91,  92,  163,  253,  255,  313-317 

Protection  against         .         .         .         .         .         .         .         .         .        148,  164 

Resistance  to        . 113,  163,  186 

Sources .         160,  254,  255 

Susceptibility  to  . 162,  186 

Infectious  diseases  : 

Classes .         .         .        .        160,  245 

Control 156.  246 

Information  for  Consumptives  and  Those  Living  with  Them        .         .        267-269 
Insane,  Tent  treatment  for  tuberculous        .......       349 

Inspection  of    apartments  occupied  by  consumptives,    in   New 

York  City 98,  340 

Institutions  where  Tuberculous  Patients  may  Receive  Treati?tent 

in  New  York  City  and  Vicinity,  by  Charles  H.  Johnson  .         .         347-355 
Intemperance,  see  Alcohol,  Alcoholism. 

378 


Iowa,  Sanatoria  for  consumptives        .......        234,  359 

Irish  in  the  United  States,  Consumption  among  .         .         .         .53,  60,  88,  go,  91 

Italians  in  the  United  States,  Consumption  among      .         .   55,  60,  61,  90,  91,  102 

Jacobi,  A.,  M.D iii.,  141 

Tuberculosis  and  Children    . 9,11,207-224 

James,  Walter  B.,  M.D iii.,  344 

Japanese  in  the  United  States,  Consumption  among    .....         49 

Jews,  see  Hebrews.   ■ 

Johnson,  Charles  H 138,  I39.  Uo,  141 

Institutions  -where    Tuberculous  Patients  may  Receive  Treat- 
ment, in  New  York  City  and  Vicinity  .....        347-355 

Kaplen,  Paul,  M.D 142 

Kennedy,  F.  S.,  M.D 139,  140,  141,  142 

Kilmer,  T.  W.,  M.D.  .         . 139 

King's  County  Hospital,  Brooklyn 300,  360 

Knopf,  S.  A.,  M.D.    .         .         .  iii.,  6,  10,  137,  138,  140,  163,  328,  329,  353 

Brief  List  of  Important  Works  in  Regard  to  Tuberculosis     .  .13,  365-369 

Duties  of  the  Individual  and  the  Governtnent  in  the  Combat 

of  Tuberculosis      .........   9,  173-204 

Sanatoria   and  Hospitals  for    Cofisumptives  in   the    United 

States  and  Canada  .         .         .         .         .         .         .         .        359-361 

Koch,  Robert,  M.D.: 

Discoveries  ..........        145,  156,  157 

Observations  in  regard  to  bovine  tuberculosis        ....       165,  203 

Use  of  name,  by  quack  concerns  .......       195 

Korosi,  Dr 78 

Leaflet :  Warfare  against  Consumption        .....         10,  263,  264 

Lecturers  for  the  Committee        ........   9,  137-142 

Lectures  delivered  under  the  auspices  of  the  Committee       .         .      9,  10,  137-142 
Lederle,  Ernst  J.         .........         .    iii.,  3,  269 

Le  Fevre,  Egbert,  M.D iii.,  137 

Life,  Average  length  of       .         .         .         .         .         .         .         .         .         41,  154 

Lincoln  Hospital  and  Home,  New  York  City      ......       349 

Literature  distributed  by  the  Committee      .......  10-12 

Locality,  Variations  in  prevalence  of  consumption  according  to   .         .         .  80-92 

Loomis,  Henry  P.,  M.D .         .  iii.,  98,  139,  142,  352 

Climatic  and  Sanatorium  Treatment  of  Consumption     .  .  .9,  227-239 

Loomis  Sanatorium,  Liberty,  New  York      .         .         .         236,  237,  299,  352,  360 
Louisiana,  Sanatorium  for  Consumptives  at  Covington  ....      359 

"Lung  Block,"  The    .         .         .         .         .         .         .....         .       309 

Lymph  glands.  Tuberculosis  of  ........       210 

379 


Maine,  State  sanatorium  projected      ....... 

Maine  Hospital  for  the  Insane,  Eastern       ...... 

Manhattan  State  Hospital,  East ........ 

Marital  condition,  Variations  of  death-rate  from  tuberculosis  ac- 
cording to  .........         . 

Maryland,  Sanatoria  for  consumptives         ...... 

Massachusetts,  Sanatoria  for  consumptives  ..... 

Massachusetts  State  Sanatorium,  Rutland    ....         128,  234, 

Meat  from  tuberculous  cattle       ........ 

Meningitis,  Tubercular        ......... 

Metropolitan  Hospital,  Blackwell's  Island,  New  York, 

125-133,  297,  299,  300, 
Milk  of  tuberculous  cows     .         .         .         .         .         .         .         .184, 


.       234 

•       349 

349.  360 


•  43-47 

■       359 

.       359 

298,  359 

214,  247 

209 


Milk  and  meat  supply.  Supervision  of  .         .         . 

Miller,  J.  A.,  M.D 

Management  of  Cases  of  Pulmonary    Tuberculosis  in    the 
Dispensary    .  ...... 

Millett  Sanatorium,  East  Bridgewater,  Massachusetts 
Minnesota,  Hospital  for  tuberculous  prisoners    . 
Mississippi  Hospital  for  tuberculous  insane 
Montefiore  Country  Sanitarium,  Bedford,  New  York 
Montefiore  Home,  New  York  City      .... 

Montreal,  Protestant  Hospital  for  the  Insane 
Montreal  Sanatorium  for  Consumptives 
Mortality,  see  Death-rate. 
Mount  St.  Rose  Sanatorium,  St.  Louis,  Missouri 

Mulberry  Bend 

Municipal  government.  Duties  of,  in  the  combat  of  tuberculosis 
Municipal  sanatorium  for  New  York,  see  Sanatorium. 
Municipal  Tuberculosis  Sanatorium,  Cleveland,  Ohio 
Muskoka  Cottage  Sanatorium,  Gravenhurst,  Ontario 


98,  li 


301,  347 
215,  247 
218,  256 

•  13,  14 

334-344 

•  359 
■       359 

•  359 
353,  360 
353,  360 

•  349 
361 


201, 


•      359 

88 
256,  257 

360 
361 


National  Jewish  Hospital  for  Consumptives,  Denver,  Colorado           .         .       359 
Nationality,  Variations  of  death-rate  from  tuberculosis  accord- 
ing to        53-57 

Negroes  : 

Consumption  among     .         .         .         .         .         .         .         .        50-52,  60,  88 

Effect  of  city  life  on  health 51.52 

New  Jersey  State  Sanatorium      .........       234 

New  Mexico,  Sanatoria  for  consumptives    ......        359,  3^° 

New  York,  Sanatoria  for  consumptives        .         .         .         .         .         .         .       360 

New  York  City  :  see 

Committee  on  the  Prevention  of  Tuberculosis. 

Department  of  Health. 

Sanatoria. 

380 


New  York  City — Continued. 

Sanatorium,  Municipal. 

Statistics. 

Tenements. 

Tenement  House  Department. 

Tuberculosis. 

New  York  Medical  Record .         .         vi,,  331 

New  York  State  Hospital  for  Incipient  Cases  of  Tuberculosis     .  14,  i68,  234 

Nordrach  Ranch,  Colorado  Springs,  Colorado     ......       359 

North  Carolina,  Sanatoria  for  consumptives         ......       360 

North  Dakota,  Sanatorium  for  consumptives,  Minot    .         .         .         .         .       360 

Nott  Home  of  Jewish  Hospital,  Philadelphia,  Pennsylvania         .         .         .       361 
Nurses,  Visiting,  Importance,  in  dispensary  treatment  of  tuber- 
culosis               340,  342 

Oak  Park  Sanatorium  for  Consumptives,  Minot,  North  Dakota  .         .         .       360 
Occupation  : 

of  patients  in  the  Tuberculosis  Infirmary,  Blackwell's  Island         .        129,  130 

Variations  of  death-rate  from  consumption  according  to        .         .         .  62-74 

Occupations  in  which  consumption  is  unusually  prevalent .  65,  67,  70,  73,  190 

Odell,  B.  B 15-20 

Ohio,  Sanatoria  for  consumptives         ........       360 

Ohio  State  Hospital  for  the  Insane      ........       349 

Over-crowding,  Relation  to  tuberculosis       ......  74,  253 

See  also  Tenements. 
Over-exertion,  Influence  on  susceptibility  to  tuberculosis     .         .  74,  198,  210 

Parents,  Duties  of  consumptive  .         .         .         .         .         .         .         .         .       187 

Parry,  Angenette,  M.D 138,  139 

Patent  medicines n,  12,  194,  195,  197,  324,  327 

Pennsylvania,  Provision  for  consumptives    ......        360,  361 

Peritoneal  tuberculosis  ..........       208 

Philanthropists,  Duties  of,  in  the  combat  of  tuberculosis     ....       199 

Phillips,  W.  C,  M.D 138,  140,  141,  142 

Phipps  Institute,  Philadelphia,  Pennsylvania       ......       200 

Phthisis,  see  Tuberculosis,  Pulmonary. 

Phthisis  Infirmary,  see  Tuberculosis  Infirmary. 

Pineshire  Sanitarium,  Southern  Pines,  North  Carolina         ....       360 

305-330 

33 

60,  61,  102 

iii. 

305-330 

208 

108 


Plague,  The,  in  Its  Stronghold,  by  Ernest  Poole 
Pneumonia,  Increasing  importance  as  a  cause  of  death 
Poles  in  the  United  States,  Consumption  among 
Poole,  Ernest      ........ 

The  Plague  in  Its  Stronghold        .... 

Pott's  disease       ........ 

Poverty,  Relation  to  tuberculosis  .... 

381 


55 


Predisposition  to  tuberculosis  : 

Acquired       ........ 

Inherited      ........ 

Methods  for  overcoming 
Prescott  Reception  Cottage,  Saranac  Lake,  New  York 
Press,  Duties  of,  in  the  combat  of  tuberculosis     . 
Prevention,  see  Tuberculosis,  Prevention. 
Preventive  medicine.  Developments  in 
Prudden,  T.  Mitchell,  M.D. 

Tuberculosis  and  Its  Prevention  . 

Pryor,  J.  H.,  M.D 

Publications  of  the  Committee     . 


Race,  Variations  of  death-rate  from  consumption  according  to 
Rate  of  improvement    in  death-rate    from  consumption,  Varia- 
tions in      ........         . 

Recreation,  Importance,  in  relation  to  consumption    . 

Reed,  Dr.  

Registration  area  of  the  United  States,  Explanation    . 
Registration  of  living  cases  of  pulmonary  tuberculosis  in  New 

York  City 

Relief  funds  needed  for  the  care  of  indigent  consumptives 
Relief  work  of  the  Committee      ...... 

Renovation  of  apartments  occupied  by  consumptives  . 
Renwick,  Aspinwall,  &  Owen,  Plans  for  a  municipal  sanatorium 
Resistance  to  infection         ....... 

Treatment  for  increasing      .         .         .         .         ,         . 

Rest  in  the  treatment  of  tuberculosis  .... 

Resthaven,  Morrison,  Colorado  . 

Riverside  Hospital,  North  Brother  Island,  New  York 

Robbins,  Jane,  M.D. 

Ross,  Observations  in  regard  to  yellow  fever,  in  Cuba 
Roumanians  in  the  United  States,  Consumption  among 
Rush  Hospital,  Philadelphia        ...... 

Russians  in  the  United  States,  Consumption  among    . 


l86,  i88,  190,  251 
162,  187,  249,  250 
188,  212,  256 
360 
.   194 


St.  Ann  Sanatorium  for  Consumptives,  Chicago,  Illinois 
St.  Elizabeth  Hospital,  Chicago,  Illinois     .... 
St.  Joseph's  Hospital  for  Consumptives,  New  York  City 
St.  Joseph's  Retreat,  Asheville,  North  Carolina 
St.  Joseph's  Sanatorium,  Silver  City,  New  Mexico 
Saloon,  Relation  to  consumption  ..... 

See  also  Alcohol. 
Sanatoria  and  Hospitals  for  Consutnptives  in  the  United  States 
and  Canada.     A  Partial  List    .         .         .         . 

383 


.  156 
iii.,  98,  148 
10,  243-259 

•   ,  303 
8,  10,  II,  12 

47-62,  86,  102 


79. 


92-107 

131,  199 
140 

33 

,  98,  167 

23 

.  20,  21 


[63, 


55,  60 


275-284 
250, 251 
212,  264 

•  337 

•  359 
349.  360 

.   139 

.   156 

60,  61 

360 

,  61,  102 


.   359 

.   359 

299,  348,  360 

360 

•   359 
.  68,  79,  132 


359-361 


Sanatoria  for  consumptives : 

Air  of,  free  from  tubercle  bacilli  . 

Average  cost  of  maintenance 

Construction  ..... 

Effect  on  health  of  the  neighborhood    . 

in  Germany  .         .         ,         •         . 

Need  for       ...... 

Seaside,  for  children     .... 
Sanatorium,  Municipal,  for  New  York  City 

Need  for       .         .         .         . 

Plans  


...         .         .         .161 

298,  299 

236 

16 

232,  233 

,     13,  23,  199,  203,  235,  328,  355 
24,  199,  203,  237,  328 

13,  167,  168,  274,  293,  322,  335,  355 
.    15,  273-284,  287-290,  297 
297 

293-302 
15,  293 


Probable  expenses,  for  land,  building,  and  maintenance 
Report  to  the  Board  of  Estimate  and  Apportionment  from 

the  Commissioner  of  Public  Charities 
Resolutions  of  Board  of  Aldermen 
Site  : 

Amount  of  ground  required  . 
Consents  required 
Desirable  characteristics 
Sanatorium  treatment  for  consumptives 
Advantages  ..... 

Description  .... 

History         ..... 

Results  ..... 

Sanitary  federation  projected  in  France 
Scandinavians  in  the  United  States,  Consumption  among 
Schedule  for    Recording    the    Social  History   of  Cases  of  Con- 
su7nption  ....... 

Scotch  in  the  United  States,  Consumption  among 
Scranton  Sanatorium,  Scranton,  Pennsylvania 
Scrofula       ........ 

Seaside  Sanatoria  for  tuberculous  children  . 
Seton  Hospital,  New  York  City  .... 

Sex  and  age,  Variations  of  death-rate  from  tuberculosis  accord- 
ing to    .........         . 

Sex,   Variations  in    prevalence  of  consumption  among  different 
nationalities,  according  to  ...... 

Sharon  Sanatorium,  Sharon,  Massachusetts  .         . 

Social  Aspects  of  Tuberculosis,  Based  071  a  Study  of  Statistics,  by 
Lilian  Brandt    .         .         .         .         .         . 

Social  Aspects  of  the  Tuberculosis  Infirmary,  BlackwelV s  Island, 
by  Hon.  Homer  Folks       ....... 

Social  consequences  of  tuberculosis      ...... 

Social  factors  in  the  prevalence  of  tuberculosis    .         .         .    -     . 
Sputum  cups  and  flasks        ........ 

383 


296 
296 

•  295 
232-239 
232,  233 
234,  235 

•  233 
.  238 
.   114 

54,  61,  62 


117-122,  126,  127,  128 

60,  61 

360 

192 

24,  199,  203,  237,  328 

299,  348,  360 


36-42 

59-63 
359 


8,  31-115 

3,  123-133 
107-111 

•  35-79 
179-183 


PAGE 

Sputum  of  consumptives : 

Bacteriological  examination  made  free  of  charge  by  New 

York  Health  Department       ........         gg 

Danger  from         ......  146,  158,  isg,  175,  248,  252 

Proper  care  of      ....         .  160,  175-184,  223,  248,  252,  264,  268 

Stadtmuller,  N.,  M.D I3g 

State  government,  Duties  of,  in  the  combat  of  tuberculosis  .         .        202,  256 

State  Hospital  for  Incipient  Cases  of  Tuberculosis,  Raybrook, 

New  York  .........  14,  168,  354 

States,  Variations  in  the  prevalence  of  consumption  according  to         .         .  80-84 
Statistical  study  of  the  social  aspects  of  tuberculosis     ....  31-115 

Purpose         .         .         .         .         .         .         .         .         .         .         .4,  31,  32 

Value 111-113 

Statistics  :   Sec  also  Death-rates. 

Table  i.     Mortality  in  the  registration  area  of  the  United 

States,  igoo,  by  sex        .........         36 

Table  2.     Mortality  in  the  registration  area  of  the  United 

States,  igoo,  by  sex  and  age  ........         37 

Table  3.     Mortality  from  tuberculosis  in   New  York  City, 

igoo,  by  age  and  sex      .........         38 

Diagram  I.,  representing  Table  3         .......         3g 

Table  4.     Proportion    of  mortality  caused  by  consumption 
and  by  all  tubercular  diseases  in  New  York  City,  igoo, 
by  age  and  sex       ..........         40 

Diagram  II.,  representing  Table  4        .......         40 

Diagram  III.     Proportion  of  mortality  caused  by  consump- 
tion and  by  certain  other  diseases  in  New  York  City, 
igoi,  among  men  and  among  women  20-2g  and  30-44 
years  of  age  ...........         42 

Table  5.     Death-rates  by  marital  condition,  sex,   and  age, 

in  the  registration  area  of  the  United  States,  igoo         ...         43 
Diagram  IV.,  representing  Table  5       .......         44 

Table  6.     Number  of  deaths  caused  by  consumption  per  100 
deaths  from  all  causes,  in  certain  groups  of  the  popula- 
tion  of    the    registration    area,    classified   according   to 
marital  condition,  sex,  and  age      .......         45 

Diagram  V.,  representing  Table  6         .         .         .         .         .         .         .         46 

Table  7.     Mortality  in  the  registration  area,  by  color  ....         48 

Table  8.     Percentage  of  population  at  certain  age-periods, 

by  color         ...........         48 

Table  g.     Mortality  of  the  white  population  and  of  the  col- 
ored races  in  the  registration  area,  igoo         .         .  ...         49 

Table  10.     Mortality  from  consumption  in  certain  southern 
cities  and  in  the  rural  part  of  certain  southern  states, 
1900,  by  color        ..........         51 

384 


Statistics —  Continued. 

Diagram  VI.,  representing  Table  lO 

Table  ii.  Mortality  from  consumption,  15-44  years  of  age, 
in  the  registration  area,  1900,  by  color  and  nationality  . 

Diagram  VII.,  representing  Table  11 

Table  12.  Importance  of  consumption  as  a  cause  of  death 
among  the  men  and  the  women  15-44  years  of  age  in 
certain  national  groups  in  Manhattan  and  Bronx,  in 
ig02,  and  in  the  registration  area  of  the  United  States, 
1900      .....••••• 

Diagram  VIII.,  representing  Table  12  .... 

Table  13.  Population,  deaths,  and  death-rates  of  males  in 
the  registration  states,  1900,  by  classes  of  occupations    . 

Diagram  IX.  Death-rates  from  consumption,  of  men  in 
fifty-three  occupations,  in  the  registration  area,  1900     . 

Table  14.  Population,  deaths,  and  death-rates,  of  females 
in  the  registration  states,  1900,  by  occupations 

Table  15.  Proportion  of  deaths  caused  by  consumption, 
among  men  engaged  in  fifty-one  occupations,  in  Man- 
hattan and  Bronx,  1902  ...... 

Table  16.  Death-rates  in  the  340  registration  cities  of  the 
United  States,  classified  according  to  size 

Table  17.  Mortality  rates  in  the  twelve  largest  cities  of  the 
United  States,  1901 

Diagram  X.,  representing  Table  17      . 

Diagram  XI.  Proportion  of  deaths  caused  by  consumption 
in  the  states  of  the  United  States,  1900.     (Shaded  map). 

Diagram  XII.  Proportion. of  deaths  caused  by  consumption 
in  the  states  of  the  United  States,  1900.  (States 
arranged  in  order.)         .....-• 

Table  18.  Importance  of  various  elements  in  the  population 
of  the  states,  1900  ....... 

Table  19.  Density  of  population  and  death-rates  from  con- 
sumption in  Manhattan,  by  wards,  1S90  and  1900 

Diagram  XIII.,  representing  Table  19         ...         . 

Diagrams  XIV.-XVIII.  Cases  of  consumption  reported 
to  the  New  York  Board  of  Health,  1 894-1902,  by 
houses : 

Chinatown  . 
A  Syrian  district   . 
An  Irish  district  . 
An  Italian  district 
Diagram  XVIII.     A  Hebrew  district 
Table  20.     Decrease  in  general  and  consumption  death-rates 
in  the  registration  area,  1890-1900         .... 
385 


Diagram  XIV. 
Diagram  XV. 
Diagram  XVI. 
Diagram  XVII. 


52 

53 

54 


58 
59 

65 

66 

69 

72 

75 

77 
78 


82 

84 

85 
87 


89 
90 
90 
91 

92 


Statistics — Continued. 

Table  21.     Decrease  in  consumption  death-rate  in  the  urban 
and  the  rural  population  of  the  registration  area,  1890- 

1900 

Diagram  XIX.,  representing  Table  21  .... 

Table  22.     Death-rates  in  New  York  City  and  in  the  United 

States  in  certain  years  between  1881  and  1902 
Diagram  XX.,  representing  Table  22  . 

Table  23.     Death-rate,  number  of  deaths,  and  other  data 
concerning  tuberculosis  in  the  City  of  New  York,  from 

1881  to  1902 

Diagram  XXI.     Decrease  in  consumption  in  the  wards  of 

Manhattan,  1890-1901 

Table  24.     Death-rates  from  consumption  in  the  registration 

area,  by  age-periods  and  sex,  in  1890  and  in  1900 
Diagram  XXII.,  representing  Table  24 

Stella,  Antonio,  M.D 

Stony  Wold  Sanatorium,  Lake  Kushaqua,  New  York 
Sunshine  in  the  treatment  of  consumption  . 
Susceptibility  to  tuberculosis.  Variations  in 

See  also  Predisposition. 
Sweat-shop  work,  Danger  of  infection  from 
Syrians  in  the  United  States,  Consumption  among 


95 
94 

95 
96 


99 
103 


138, 


104 
.  105 
139.  141 

354,  360 

229,  230 

162 


308,  3 


315.  329 
,  91 


Teachers,  Duties  of,  in  the  combat  of  tuberculosis         ....     192,  223 

Tenement  House  Department  of  New  York  City  : 

Influence  on  general  sanitary  conditions         ......         97 

Records        ............         88 

Value,  in  the  work  of  controlling  tuberculosis        .         .         .'        .         .       321 
Tenement  House  Law,  Proposed  changes  in        ....         .         21,  202 

Tenements  of  New  York  City,  Consumptives  in  : 

Estimated  number 167,  308 

Stories 109-111,305-330 

Tent  Colony  of  Dr.  Stubbert,  Liberty,  New  York 360 

Tent  treatment  of  tuberculosis 297,  349 

Texas,  Sanatoria  for  consumptives        .  .  .  .  .  .  •  .       3^1 

Tolson,  G.  R.,  M.D.,  Private  sanatorium  of,  Covington,  Louisiana         .         .       359 

Trudeau,  E.  L.,  M.D iii.,  230,  238,  259,  344,  352 

Tubercle 146,  158,  I73,  247 

Tubercle  bacillus,  see  Bacillus  tuberculosis. 

Tuberculosis  and  Children,  hy  K.  ]eic6b\,lsV.D 207-224 

Tuberculosis  and  Its  Prevention,  by  T.  Mitchell  Prudden,  M.D.  10,  243-259 

Tuberculosis — Its  Causation  and   Prevention,  by  Hermann   M. 

Biggs,  M.D 10,  151-169 

386 


PAGE 

Tuberculosis : 

among  children 41.  192,  207-224 

Causes  214-218 

Forms 208 

Rules  for  preventing      ........        218-224 

Bibliography  of  important  works  ......        365-369 

Bovine qS, 146,  I57,  165 

Causes 156,  I57,  I59-  160,  165,  307 

See  also  Bacillus  tuberculosis. 
Committee    on   the   Prevention    of,  of  New  York  City,   see 
Committee. 

Communicability 160,  173,  252 

Curability     .         . 32,  m,  191.  238,  258 

Definition     .  .' 157,  I73.  207 

Eradication 111,157,168,307,308 

Forms 158,  186,  207-210,  247 

Infirmary,  Blackwell's  Island        .         .         .         .         .         .9,  125-133,  360 

Inheritance,  extremely  rare  .         .         .         .         .32,  162,  165,  211,  249,  250 

Prevalence    .  .         .         .  .         .         .         .  162,  207,  243,  306,  333 

Social  factors  in     .........         .  35-79 

Prevention    ......    32,  iii,  156,  160,  165,  191,  249,  306 

Cost 167,  169,  326,  327,  328 

Methods         .         .  .     in-115,  168,  248,  252,  256-259,  321,  326-330 

Organizations  for  .  .         .         .         .         .         ,         .   4,  114,  168,  227 

Pulmonary  : 

Definition      .  ..........       I73 

Distribution  ...........  80-92 

Economic  loss  entailed  by      .....         .         108,  165,  166 

Importance  as  a  cause  of  death      .....     32-35,  207,  243 

See  also  Death-rate  from  consumption. 
Importance  as  a  social  problem     ....     32,  35,  107-111,  328 

Registration 88,  98,  167,  257 

Symptoms     ...........       174 

Treatment 191,  227-237,  333,  336 

Provision  for,  in  New  York    ......         347-355 

See  also  Consumptives. 

Resistance  to 163,  212,  250,  251 

Social  aspects       ..........      8,  31-115 

Susceptibility  to 162,  186-188,  190,  212,  249-251,  256 

Tumors,  Tubercular  ...........       209 

United  Hebrew  Charities  of  New  York  City        ....        log,  350,  351 

United  States  Public  Health  and  Marine  Hospital  Service  Sana- 
torium, Capitan,  New  Mexico       .         .         .         .         ...         .         .       360 

Utah,  Consumption  in  ..........         80 

387 


PAGE 

Valadier,  C.  S.,  M.D 141 

Vanderbilt  Clinic,  New  York  City        ......  13,  336-343 

Variations  in   prevalence   of   consumption    and    in    decrease   in 

death-rates,  see  Death-rates  from  consumption. 

Vedin,  Augusta,  M.D.         .........         .  i3g 

Vermont  State  Hospital  for  Insane      ........  349 

Vienna  General  Hospital,  Autopsies  in         .....         ^         .  162 

Vinton,  Maria,  M.D. 137 

Ward's  Island,  Care  of  tuberculous  insane  .......  349 

Wards  of  Manhattan  ; 

Death-rate  from  consumption        ........  86 

Density  of  population  ..........  85 

Warfare  against  Consumption.     Leaflet  issued  by  the  Committee  10,  263-264 

Watson,  H.  G.,  M.D 140 

Willets,  Mary,  M.D 138 

Winyah  Sanitarium,  Asheville,  North  Carolina  ......  360 

Yellow  fever,  Restriction  and  control  of      ......         .       156 

Zwisohn,  L.  W.,  M.D.        ..........       140 


388 


DUE  DATE 

i 

1 

Printed 
in  USA 

COLUMBIA  UNIVERSITY  LIBRARIES 


0022319093 


RC311 


C37 


Copy  2 
Charity  organization  society 


^^'^MB.AUNryERS,TYL>BRAB|| 


00223 19 '1 07 


B33tX^',:^^. 


